Create Your Patient Account
Please fill out the form below to get started.
Personal Information
First Name
Last Name
Date of Birth
Pick a date
Phone Number
Email Address
Address & Insurance
Street Address
City
State
Zip Code
Insurance Provider
Policy Number
Emergency Contact
Contact Name
Relationship
Contact Phone
Brief Medical History
Please check any of the following that apply to you.
History of skin cancer
Eczema or Dermatitis
Psoriasis
Acne
Allergies
Rosacea
Preferences & Consents
Preferred Communication Method
Email
Text Message
Phone Call
I am interested in using DermConnect for virtual care consultations.
I acknowledge that I have read and understood the
HIPAA Notice of Privacy Practices
.
I agree to the
Terms of Service
and
Privacy Policy
.
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