Patient Forms

Adult New Patient Forms

Please print and fill out these forms so we can expedite your visit:

• Patient Information
• Office Policies
• Medical History
• Notice Of Privacy Practices

Pediatric New Patient Forms

Please print and fill out these forms so we can expedite your visit:

• Pediatric Patient Information
• Office Policies
• Medical History
• Notice Of Privacy Practices

Cosmetic Forms

Please print and fill out these forms to expedite your visit.

• Sclerotherapy Authorization
• Sclerotherapy Questionnaire
• Sclerotherapy Instructions
• Gina's Registration Form
• Botox Consent Form
• Informed Consent for Non-Invasive Cosmetic Treatments
• Micro-needling Consent Form

Laser Forms

Please print and fill out these forms to expedite your visit.

• Laser - History
• Laser - Skin type
• Laser - Hair Removal
• Laser - Genesis
• Laser - Vascular & Pigmented Lesion

Medical Records Request Forms

• Medical Records Request from Fairlawn Dermatology
• Medical Records Request to send to Fairlawn Dermatology