You can always press Enter⏎ to continue
PATIENT CONTACT FORM
Front Range Dermatology
  • 1

    Press
    Enter
  • 2
    In other words, have you been seen in our clinic within the past 3 years?
    Press
    Enter
  • 3
    Press
    Enter
  • 4
    Pick a Date
    Press
    Enter
  • 5
    NOTE: If you provide us with your email, then you are giving us express permission to communicate with you via email. If this is not acceptable, please only provide us with your phone number.
    Press
    Enter
  • 6
    Press
    Enter
  • 7
    Press
    Enter
  • 8

    Please understand that we must perform a consultation at least once yearly (though sometimes sooner) in order to authorize medication refills. Such consultations are now available via "virtual visit" and we invite you to learn more:

    Press
    Enter
  • 9
    Press
    Enter
  • 10
    TextSizeCreated with Sketch.
    • Huge
    • Large
    • Normal
    • Small
    BoldCreated with Sketch.
    ItalicCreated with Sketch.
    UnderlineCreated with Sketch.
    Underline CopyCreated with Sketch.
    Ok
    NumberList Copy 2Created with Sketch.
    quoteCreated with Sketch.
    BreakCreated with Sketch.
    ImageCreated with Sketch.
    Ok
    SmileyCreated with Sketch.
    Press
    Enter
  • 11
    NOTE: Be sure to monitor the upload progress to ensure image(s) fully uploaded before moving to next screen.
    Drag and drop files here
    Select files to upload
    Max. file size: 10.6MB
    Cancelof
    Press
    Enter
  • 12
    TextSizeCreated with Sketch.
    • Huge
    • Large
    • Normal
    • Small
    BoldCreated with Sketch.
    ItalicCreated with Sketch.
    UnderlineCreated with Sketch.
    Underline CopyCreated with Sketch.
    Ok
    NumberList Copy 2Created with Sketch.
    quoteCreated with Sketch.
    BreakCreated with Sketch.
    ImageCreated with Sketch.
    Ok
    SmileyCreated with Sketch.
    Press
    Enter
  • 13
    Press
    Enter
  • 14
    Please note that if you were scheduled to be seen within the coming weeks, we've likely already cancelled your visit due to the COVID emergency. Upon reviewing your request, we will contact you should we need any additional information.
    Press
    Enter
  • 15

    First, please take a moment to learn about teledermatology...

    Press
    Enter
  • 16
    Press
    Enter
  • 17
    TextSizeCreated with Sketch.
    • Huge
    • Large
    • Normal
    • Small
    BoldCreated with Sketch.
    ItalicCreated with Sketch.
    UnderlineCreated with Sketch.
    Underline CopyCreated with Sketch.
    Ok
    NumberList Copy 2Created with Sketch.
    quoteCreated with Sketch.
    BreakCreated with Sketch.
    ImageCreated with Sketch.
    Ok
    SmileyCreated with Sketch.
    Press
    Enter
  • 18
    NOTE: Be sure to monitor the upload progress to ensure image(s) fully uploaded before moving to next screen.
    Drag and drop files here
    Select files to upload
    Max. file size: 10.6MB
    Cancelof
    Press
    Enter
  • 19
    Drag and drop files here
    Select files to upload
    Max. file size: 10.6MB
    Cancelof
    Press
    Enter
  • 20
    TextSizeCreated with Sketch.
    • Huge
    • Large
    • Normal
    • Small
    BoldCreated with Sketch.
    ItalicCreated with Sketch.
    UnderlineCreated with Sketch.
    Underline CopyCreated with Sketch.
    Ok
    NumberList Copy 2Created with Sketch.
    quoteCreated with Sketch.
    BreakCreated with Sketch.
    ImageCreated with Sketch.
    Ok
    SmileyCreated with Sketch.
    Press
    Enter
  • 21
    Press
    Enter
  • 22
    Press
    Enter
  • 23
    Press
    Enter
  • 24

    Please understand that we must perform a consultation at least once yearly (though sometimes sooner) in order to authorize medication refills. Such consultations are now available via "virtual visit" and we invite you to learn more:

    Press
    Enter
  • 25
    Press
    Enter
  • 26
    TextSizeCreated with Sketch.
    • Huge
    • Large
    • Normal
    • Small
    BoldCreated with Sketch.
    ItalicCreated with Sketch.
    UnderlineCreated with Sketch.
    Underline CopyCreated with Sketch.
    Ok
    NumberList Copy 2Created with Sketch.
    quoteCreated with Sketch.
    BreakCreated with Sketch.
    ImageCreated with Sketch.
    Ok
    SmileyCreated with Sketch.
    Press
    Enter
  • 27
    Drag and drop files here
    Select files to upload
    Max. file size: 10.6MB
    Cancelof
    Press
    Enter
  • 28
    TextSizeCreated with Sketch.
    • Huge
    • Large
    • Normal
    • Small
    BoldCreated with Sketch.
    ItalicCreated with Sketch.
    UnderlineCreated with Sketch.
    Underline CopyCreated with Sketch.
    Ok
    NumberList Copy 2Created with Sketch.
    quoteCreated with Sketch.
    BreakCreated with Sketch.
    ImageCreated with Sketch.
    Ok
    SmileyCreated with Sketch.
    Press
    Enter
  • 29
    Press
    Enter
  • 30
    Please note that if you were scheduled to be seen within the coming weeks, we've likely already cancelled your visit due to the COVID emergency. Upon reviewing your request, we will contact you should we need any additional information.
    Press
    Enter
  • 31

    First, please take a moment to learn about teledermatology...

    Press
    Enter
  • 32
    Press
    Enter
  • 33
    TextSizeCreated with Sketch.
    • Huge
    • Large
    • Normal
    • Small
    BoldCreated with Sketch.
    ItalicCreated with Sketch.
    UnderlineCreated with Sketch.
    Underline CopyCreated with Sketch.
    Ok
    NumberList Copy 2Created with Sketch.
    quoteCreated with Sketch.
    BreakCreated with Sketch.
    ImageCreated with Sketch.
    Ok
    SmileyCreated with Sketch.
    Press
    Enter
  • 34
    NOTE: Be sure to monitor the upload progress to ensure image(s) fully uploaded before moving to next screen.
    Drag and drop files here
    Select files to upload
    Max. file size: 10.6MB
    Cancelof
    Press
    Enter
  • 35
    Drag and drop files here
    Select files to upload
    Max. file size: 10.6MB
    Cancelof
    Press
    Enter
  • 36
    TextSizeCreated with Sketch.
    • Huge
    • Large
    • Normal
    • Small
    BoldCreated with Sketch.
    ItalicCreated with Sketch.
    UnderlineCreated with Sketch.
    Underline CopyCreated with Sketch.
    Ok
    NumberList Copy 2Created with Sketch.
    quoteCreated with Sketch.
    BreakCreated with Sketch.
    ImageCreated with Sketch.
    Ok
    SmileyCreated with Sketch.
    Press
    Enter
  • 37
    Press
    Enter
  • 38
    Press
    Enter
  • 39
    Press
    Enter
  • 40

    Please understand that we must perform a consultation at least once yearly (though sometimes sooner) in order to authorize medication refills. Such consultations are now available via "virtual visit" and we invite you to learn more:

    Press
    Enter
  • 41
    Press
    Enter
  • 42
    TextSizeCreated with Sketch.
    • Huge
    • Large
    • Normal
    • Small
    BoldCreated with Sketch.
    ItalicCreated with Sketch.
    UnderlineCreated with Sketch.
    Underline CopyCreated with Sketch.
    Ok
    NumberList Copy 2Created with Sketch.
    quoteCreated with Sketch.
    BreakCreated with Sketch.
    ImageCreated with Sketch.
    Ok
    SmileyCreated with Sketch.
    Press
    Enter
  • 43
    NOTE: Be sure to monitor the upload progress to ensure image(s) fully uploaded before moving to next screen.
    Drag and drop files here
    Select files to upload
    Max. file size: 10.6MB
    Cancelof
    Press
    Enter
  • 44
    TextSizeCreated with Sketch.
    • Huge
    • Large
    • Normal
    • Small
    BoldCreated with Sketch.
    ItalicCreated with Sketch.
    UnderlineCreated with Sketch.
    Underline CopyCreated with Sketch.
    Ok
    NumberList Copy 2Created with Sketch.
    quoteCreated with Sketch.
    BreakCreated with Sketch.
    ImageCreated with Sketch.
    Ok
    SmileyCreated with Sketch.
    Press
    Enter
  • 45
    Press
    Enter
  • 46
    Please note that if you were scheduled to be seen within the coming weeks, we've likely already cancelled your visit due to the COVID emergency. Upon reviewing your request, we will contact you should we need any additional information.
    Press
    Enter
  • 47

    First, please take a moment to learn about teledermatology...

    Press
    Enter
  • 48
    Press
    Enter
  • 49
    TextSizeCreated with Sketch.
    • Huge
    • Large
    • Normal
    • Small
    BoldCreated with Sketch.
    ItalicCreated with Sketch.
    UnderlineCreated with Sketch.
    Underline CopyCreated with Sketch.
    Ok
    NumberList Copy 2Created with Sketch.
    quoteCreated with Sketch.
    BreakCreated with Sketch.
    ImageCreated with Sketch.
    Ok
    SmileyCreated with Sketch.
    Press
    Enter
  • 50
    NOTE: Be sure to monitor the upload progress to ensure image(s) fully uploaded before moving to next screen.
    Drag and drop files here
    Select files to upload
    Max. file size: 10.6MB
    Cancelof
    Press
    Enter
  • 51
    Drag and drop files here
    Select files to upload
    Max. file size: 10.6MB
    Cancelof
    Press
    Enter
  • 52
    TextSizeCreated with Sketch.
    • Huge
    • Large
    • Normal
    • Small
    BoldCreated with Sketch.
    ItalicCreated with Sketch.
    UnderlineCreated with Sketch.
    Underline CopyCreated with Sketch.
    Ok
    NumberList Copy 2Created with Sketch.
    quoteCreated with Sketch.
    BreakCreated with Sketch.
    ImageCreated with Sketch.
    Ok
    SmileyCreated with Sketch.
    Press
    Enter
  • 53
    Press
    Enter
  • 54
    TextSizeCreated with Sketch.
    • Huge
    • Large
    • Normal
    • Small
    BoldCreated with Sketch.
    ItalicCreated with Sketch.
    UnderlineCreated with Sketch.
    Underline CopyCreated with Sketch.
    Ok
    NumberList Copy 2Created with Sketch.
    quoteCreated with Sketch.
    BreakCreated with Sketch.
    ImageCreated with Sketch.
    Ok
    SmileyCreated with Sketch.
    Press
    Enter
  • 55

    Sorry, it looks like you've already submitted this before (can't choose same option twice).

    Press
    Enter
  • 56

    First, please take a moment to learn about teledermatology...

    Press
    Enter
  • 57
    Press
    Enter
  • 58
    TextSizeCreated with Sketch.
    • Huge
    • Large
    • Normal
    • Small
    BoldCreated with Sketch.
    ItalicCreated with Sketch.
    UnderlineCreated with Sketch.
    Underline CopyCreated with Sketch.
    Ok
    NumberList Copy 2Created with Sketch.
    quoteCreated with Sketch.
    BreakCreated with Sketch.
    ImageCreated with Sketch.
    Ok
    SmileyCreated with Sketch.
    Press
    Enter
  • 59
    Press
    Enter
  • 60
    Pick a Date
    Press
    Enter
  • 61
    NOTE: If you provide us with your email, then you are giving us express permission to communicate with you via email. If this is not acceptable, please only provide us with your phone number.
    Press
    Enter
  • 62
    TextSizeCreated with Sketch.
    • Huge
    • Large
    • Normal
    • Small
    BoldCreated with Sketch.
    ItalicCreated with Sketch.
    UnderlineCreated with Sketch.
    Underline CopyCreated with Sketch.
    Ok
    NumberList Copy 2Created with Sketch.
    quoteCreated with Sketch.
    BreakCreated with Sketch.
    ImageCreated with Sketch.
    Ok
    SmileyCreated with Sketch.
    Press
    Enter
  • 63
    Drag and drop files here
    Select files to upload
    Max. file size: 10.6MB
    Cancelof
    Press
    Enter
  • 64
    Drag and drop files here
    Select files to upload
    Max. file size: 10.6MB
    Cancelof
    Press
    Enter
  • 65
    TextSizeCreated with Sketch.
    • Huge
    • Large
    • Normal
    • Small
    BoldCreated with Sketch.
    ItalicCreated with Sketch.
    UnderlineCreated with Sketch.
    Underline CopyCreated with Sketch.
    Ok
    NumberList Copy 2Created with Sketch.
    quoteCreated with Sketch.
    BreakCreated with Sketch.
    ImageCreated with Sketch.
    Ok
    SmileyCreated with Sketch.
    Press
    Enter
  • Should be Empty:
Question Label
1 of 65See AllGo Back
close
Save & Continue Later

Your form is saved successfully!

If you want to continue answering your form later, please enter the email address you would like to send the link to:

Please enter a valid email address.

Something went wrong while saving your answers. Please try again.

Email has been sent successfully.

Save your progress

OR
Already have an account? LOGIN
Skip Create an Account

Save your progress

Terms of ServicePrivacy Policy

Your form submission has been saved as a draft.

If you want to continue answering your form later, please enter the email address you would like to send the link to:

Save your progress

OR
Forgot Password?

Your form submission has been saved as a draft.

We’ve sent you an email with a link to complete your submission.

Logout