Telemedicine Patient Forms

Providing us with an accurate, up-to-date medical history will allow our physicians to tailor your course of treatment. All you have to do it click on the link below, print the form, fill it out and bring it with you to your appointment OR edit the form and email to appointments@bellairedermatology.com.

Essential Telemedicine Services

  • Acne
  • Athlete’s Foot
  • Cold Sores
  • Eczema
  • Hives
  • Melasma
  • Poison Ivy
  • Psoriasis
  • Rashes
  • Ringworm
  • Rosacea
  • Shingles
  • Skin Infection
  • Sunburn
  • New Painful or Spreading Rashes
  • New Blisters
  • New Onset of Severe Skin Pain
  • Concern of Melanoma Skin Cancer
  • Post Skin Cancer Surgery Complication
  • Post Cosmetic Procedure Complication

Complete the Telemedicine Forms

Click on the buttons to download & print the PDF forms.

Cosmetic Department Virtual Consultations

Cosmetic Department Virtual Consultations may be scheduled for $75, which will be applied toward product or service.

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Call Today To Schedule Your Appointment With Us

1-713-661-4383