Dermatology Intake Form Template
Collects contact details, skin concerns, photos, sun exposure, treatments, and medications from people preparing for a dermatology appointment.
When to use it
- Before a first dermatology appointment
- When following up on a changing skin concern
- For a remote consultation where photos may help
- When reviewing treatments and medications before a visit
What it asks
- What is your name?
- What is your email address?
- What is your phone number?
- What skin concern would you like help with?
- Where on your body is it located?
- How long have you had this concern?
- Would you like to upload photos of the concern?
- Which skin type best describes you?
- How much time do you typically spend in the sun?
- What treatments have you tried for this concern?
- What medications are you currently taking?
Why it should be encrypted
Skin photos, health details, and medication lists are private information. They should be readable only by the patient and the dermatology team handling their care.
Tips
- Explain how to take clear, well-lit photos without including unrelated personal details.
- Add a reminder to list medication names and include over-the-counter products if relevant.
- Ask patients to share only details needed for their appointment.