Prefer it online? Patients fill it out on their phone before the visit.
Practice name: ______________________________
Dermatology Intake Form
Dermatology Intake Form Please complete this form to help your dermatologist prepare for your visit. Detailed responses allow us to provide the most accurate diagnosis and treatment.
Full Name *
Date of Birth *
____ / ____ / ________
Email Address *
Phone Number *
Skin Concerns & Dermatology History Tell us about your skin health so we can address your concerns effectively.
Reason for Visit *
Area of Concern *
- Face
- Scalp
- Neck
- Chest
- Back
- Arms
- Hands
- Legs
- Feet
- Other
Duration of Skin Concern
Skin Type *
- Very Fair
- Fair
- Medium
- Olive
- Dark
- Very Dark
Current Skin Care Routine
Sun Exposure Habits *
- Minimal
- Moderate
- Frequent
Sunscreen Use *
- Daily
- Sometimes
- Rarely
- Never
History of Skin Cancer *
- Yes
- No
Family History of Skin Cancer *
- Yes
- No
Previous Dermatology Treatments
Current Medications
Drug Allergies
Dermatology Intake Form template from formisoft.com. formisoft.com/intake-templates/dermatology-intake