Dermatology Intake Form
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The Dermatology Intake Form is designed for dermatology practices, medical spas, and skin care clinics. It captures dermatology-specific information including skin concern history, sun exposure and tanning habits, skin cancer risk factors, previous skin treatments and procedures, and current skincare routine.
A standout feature is the photo upload section that allows patients to document skin lesions, rashes, or areas of concern before their appointment. This gives the dermatologist a visual baseline and helps prioritize examination areas. The skin cancer screening section covers family history of melanoma, history of blistering sunburns, and mole change documentation.
The form distinguishes between medical and cosmetic dermatology concerns, routing patients to appropriate sections. Previous treatments -- including prescription topicals, oral medications, laser treatments, injectables, and surgical procedures -- are documented with dates and outcomes. This template is also well-suited for teledermatology practices where pre-visit photo documentation is essential.
What's included
- Skin concern history and duration
- Sun exposure and skin cancer risk screening
- Patient photo documentation upload for lesions
- Previous treatment and procedure history
- Medical conditions checklist
- Consent agreement with e-signature
Who uses this template
- Dermatology practices (medical and cosmetic)
- Medical spas and aesthetics clinics
- Teledermatology services
- Skin cancer screening clinics
All form fields
12 fields across 2 pages. Customize any field after signing up.
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