New Patient Registration

Do you need to be seen by a dermatologist right away?

Same day appointments are often available!

Call Now: (480) 855-0085

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Ethnicity

Race (check one)

Relationship to Patient

Relationship to Patient (secondary)

Do you have a family history of skin cancer? *

Family History of Malignant Melanoma? *

Do you have a personal history of skin cancer? *

Personal History of Malignant Melanoma? *

Do you have a personal history of any other skin problem, such as eczema, psoriasis, dry skin, etc? If yes, please explain: *

Do you have any allergies to medications? If yes, please explain: *

Please select any of the following that apply to you:
High blood pressureDiabetesHeart diseaseHistory of strokeThyroid disordersProblems with easy bleeding/bruisingProblems with healing/scarringSuspicious lesions or changing molesHistory of blood clot/DVTAllergy to adhesive or bandagesAllergy to topical antibiotic ointmentsAllergy to lidocaineArtificial joints within past two yearsBlood thinnersRapid heart beat with epinephrine or a numbing shotPacemakerDefibrillatorArtificial heart valvePregnancy or planning a pregnancyBreastfeedingRequire antibiotic prior to procedures (due to heart valve or other condition)

Do you use sunscreen? *

Do you smoke? *

Do you use chewing tobacco? *

Have you ever used tobacco products? *

Please list all medications: *

Contact Us Today! At Desert Sky Dermatology, we love helping our patients.