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(330) 864-9000

(330) 864-9000

Fax: 330-864-9004



Fairlawn Dermatology is accredited by the Better Business Bureau.

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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

55 Merz Blvd

Fairlawn, OH 44333 US

(330) 864-9000

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