Appointment Request Form

REQUEST A TELEHEALTH VISIT

Please fill out and submit the form below to request a virtual visit with one of our providers and a member of our staff will contact you:
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Email*
example@example.com
Phone Number*

Area CodePhone Number
Are you a new or existing patient?*
1. The following problems can be addressed through telehealth visits (Choose One).*

Accutane (isotretinoin) follow upsAcne visits and follow upsEczema visitsEvaluation of specific skin lesion(s)New rashes or rash follow upsPsoriasis visitsNail evaluations and follow upsSkin infection evaluations
2. Additional information regarding your concern*
Ex: "Painful, itchy rash on face", "Bleeding, large mole on back"
3. Do you have a smartphone, tablet, or computer with a video camera and a decent internet connection? (smartphone is preferred)*
4. What type of device do you have?*

iOS (iPhone)AndroidPC or Laptop with web cameraOther
You answered "NO". A smartphone, tablet, or computer with a video camera and a decent internet connection is required to establish a Telehealth visit. You do not meet the technical requirements. If this was selected in error, please answer question number 3 "YES".
If you think pictures might help us in reviewing your request, feel free to upload them here:

UPLOAD IMAGE(S)

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Should be Empty:

REQUEST A TELEHEALTH VISIT