Front Range Dermatology

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PATIENT CONTACT FORM

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Are you an established patient of Front Range Dermatology?* This field is required.In other words, have you been seen in our clinic within the past 3 years?
Yes
No
3
Great! First, please tell us your name as it would be listed within our patient records.* This field is required.
First Name
Last Name
4
What is your date of birth?* This field is required.
DOB
Month
Day
Year
5
What is the best phone number or other method of reaching you?* This field is required.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.
6
Please choose ONE of the following:* This field is required.
I need a medication refill.
I need to cancel my next appointment.
I would like to request a consultation (regarding a follow-up or new problem).
7
Has it been over a year since you've last been seen in the clinic?* This field is required.
YESNO
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:
9
Would you like for us to contact you to schedule a teledermatology consultation ("virtual visit")?* This field is required.
Yes, please contact me to schedule.
No, I'd rather wait.
10
Please let us know which medication(s) you will be needing refilled, and also give us an update on how you're doing. Is the medication working, are you experiencing and problems, etc.?* This field is required.
Huge
Large
Normal
Small
Ok
Ok
11
In order to confirm coverage and schedule you appropriately, please upload an image of both the FRONT and BACK of your health insurance card(s).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
12
Finally, let us know a few options for a date and time that would work well to schedule your appointment. For example, "Thursday mornings I'm available" or "This coming Monday from 9-12 would work".* This field is required.
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Large
Normal
Small
Ok
Ok
13
Please ask your pharmacy to send us an electronic refill request. Once received from the pharmacy, we will contact you should we have any questions or concerns.* This field is required.
Thank you. That's all I need.
I have another concern.
14
We have received your request to cancel your next appointment.* This field is required.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.
Thank you. That's all I need.
I have another concern.
15
First, please take a moment to learn about teledermatology...
16
Would you like for us to contact you to schedule a teledermatology consultation ("virtual visit")?* This field is required.
Yes, please contact me to schedule.
No, I'd rather wait.
17
In order to schedule your online visit, we need to know as much information as you can provide about any concern(s) you'd like addressed during your teledermatology consultation.* This field is required.
Huge
Large
Normal
Small
Ok
Ok
18
If you think a picture might help us in reviewing your request, feel free to upload it here.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
19
To confirm coverage and schedule you appropriately, please submit photos (Front/Back) of your health insurance card(s).
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
20
Finally, let us know a few options for a date and time that would work well to schedule your appointment. For example, "Thursday mornings I'm available" or "This coming Monday from 9-12 would work".* This field is required.
Huge
Large
Normal
Small
Ok
Ok
21
Is there anything else we can help you with?* This field is required.
No, that's all I need.
Yes, I have another concern.
22
Please choose ONE of the following:* This field is required.
I need a medication refill.
I need to cancel my next appointment.
I would like to request a consultation (regarding a follow-up or new problem).
23
Has it been over a year since you've last been seen in the clinic?* This field is required.
YESNO
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:
25
Would you like for us to contact you to schedule a teledermatology consultation ("virtual visit")?* This field is required.
Yes, please contact me to schedule.
No, I'd rather wait.
26
Please let us know which medication(s) you will be needing refilled, and also give us an update on how you're doing. Is the medication working, are you experiencing and problems, etc.?* This field is required.
Huge
Large
Normal
Small
Ok
Ok
27
In order to confirm coverage and schedule you appropriately, please upload an image of both the FRONT and BACK of your health insurance card(s).
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
28
Finally, let us know a few options for a date and time that would work well to schedule your appointment. For example, "Thursday mornings I'm available" or "This coming Monday from 9-12 would work".* This field is required.
Huge
Large
Normal
Small
Ok
Ok
29
Please ask your pharmacy to send us an electronic refill request. Once received from the pharmacy, we will contact you should we have any questions or concerns.* This field is required.
Thank you. That's all I need.
I have another concern.
30
We have received your request to cancel your next appointment.* This field is required.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.
Thank you. That's all I need.
I have another concern.
31
First, please take a moment to learn about teledermatology...
32
Would you like for us to contact you to schedule a teledermatology consultation ("virtual visit")?* This field is required.
Yes, please contact me to schedule.
No, I'd rather wait.
33
In order to schedule your online visit, we need to know as much information as you can provide about any concern(s) you'd like addressed during your teledermatology consultation.* This field is required.
Huge
Large
Normal
Small
Ok
Ok
34
If you think a picture might help us in reviewing your request, feel free to upload it here.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
35
To confirm coverage and schedule you appropriately, please submit photos (Front/Back) of your health insurance card(s).
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
36
Finally, let us know a few options for a date and time that would work well to schedule your appointment. For example, "Thursday mornings I'm available" or "This coming Monday from 9-12 would work"* This field is required.
Huge
Large
Normal
Small
Ok
Ok
37
Is there anything else we can help you with?* This field is required.
No, that's all I need.
Yes, I have another concern.
38
Please choose ONE of the following:* This field is required.
I need a medication refill.
I need to cancel my next appointment.
I would like to request a consultation (regarding a follow-up or new problem).
39
Has it been over a year since you've last been seen in the clinic?* This field is required.
YESNO
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:
41
Would you like for us to contact you to schedule a teledermatology consultation ("virtual visit")?* This field is required.
Yes, please contact me to schedule.
No, I'd rather wait.
42
Please let us know which medication(s) you will be needing refilled, and also give us an update on how you're doing. Is the medication working, are you experiencing and problems, etc.?* This field is required.
Huge
Large
Normal
Small
Ok
Ok
43
In order to confirm coverage and schedule you appropriately, please upload an image of both the FRONT and BACK of your health insurance card(s).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
44
Finally, let us know a few options for a date and time that would work well to schedule your appointment. For example, "Thursday mornings I'm available" or "This coming Monday from 9-12 would work".* This field is required.
Huge
Large
Normal
Small
Ok
Ok
45
Please ask your pharmacy to send us an electronic refill request. Once received from the pharmacy, we will contact you should we have any questions or concerns.* This field is required.
Thank you. That's all I need.
I have another concern.
46
We have received your request to cancel your next appointment.* This field is required.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.
Thank you. That's all I need.
I have another concern.
47
First, please take a moment to learn about teledermatology...
48
Would you like for us to contact you to schedule a teledermatology consultation ("virtual visit")?* This field is required.
Yes, please contact me to schedule.
No, I'd rather wait.
49
In order to schedule your online visit, we need to know as much information as you can provide about any concern(s) you'd like addressed during your teledermatology consultation.* This field is required.
Huge
Large
Normal
Small
Ok
Ok
50
If you think a picture might help us in reviewing your request, feel free to upload it here.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
51
To confirm coverage and schedule you appropriately, please submit photos (Front/Back) of your health insurance card(s).
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
52
Finally, let us know a few options for a date and time that would work well to schedule your appointment. For example, "Thursday mornings I'm available" or "This coming Monday from 9-12 would work"
Huge
Large
Normal
Small
Ok
Ok
53
Is there anything else we can help you with?* This field is required.
No, that's all I need.
Yes, I have another concern.
54
Please use the following form to submit any other issues, questions, or concerns:* This field is required.
Huge
Large
Normal
Small
Ok
Ok
55
Sorry, it looks like you've already submitted this before (can't choose same option twice).
56
First, please take a moment to learn about teledermatology...
57
Would you like for us to contact you to schedule a teledermatology consultation ("virtual visit")?* This field is required.
Yes, please contact me to schedule.
No, I'd rather wait.
58
Due to COVID-19 safety restrictions, we are now greatly limited in our ability to perform traditional visits in the clinic. However, if you provide us with your name, the best way to reach you (phone, email, etc.), and any additional details which may help us to better understand how we can assist, we'll be happy to contact you after we've reviewed your submission.
Huge
Large
Normal
Small
Ok
Ok
59
Great! First, please tell us your name.* This field is required.
First Name
Last Name
60
What is your date of birth?* This field is required.
DOB
Month
Day
Year
61
What is the best phone number or other method of reaching you?* This field is required.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.
62
In order to schedule your online visit, we need to know as much information as you can provide about any concern(s) you'd like addressed during your teledermatology consultation.* This field is required.
Huge
Large
Normal
Small
Ok
Ok
63
If you think a picture might help us in reviewing your request, feel free to upload it here.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
64
To confirm coverage and schedule you appropriately, please submit photos (Front/Back) of your health insurance card(s).
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
65
Finally, let us know a few options for a date and time that would work well to schedule your appointment. For example, "Thursday mornings I'm available" or "This coming Monday from 9-12 would work"* This field is required.
Huge
Large
Normal
Small
Ok
Ok
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