Dermatology Associates, PSC
Cosmetic Skin Care Center


Use the text box below to enter your question or product refill request. If we have your credit card number on file in our office, we can charge it and mail your product to you at your request(add 5 dollars shipping charge).

Please fill in all blanks before submitting.

General Data

Name (Last, First, MI):
DOB (MM/DD/YYYY):
Phone (Home):
Phone (Alternate):
Are you requesting a product refill? yesno
Would you like your on-file credit card charged? yesno
Will you pick-up your product or would you like it mailed? Pick-upMail
Shipping address:
Question or order:


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Dermatology Associates, PSC; 2811 Klempner Way, Louisville, KY 40205
Office: 502-896-6355 Fax: 502-896-6357