In accordance with state and federal guidelines, masks are required at the time of your appointment!

Patient Forms


 

Patient form

Download Forms

Patient Intake Form

Notice of Privacy Practices

Financial Policy

Cosmetic & Aesthetic Policy

Check-in Forms

Especially if this is your first visit to our location, you can save time in the waiting room by downloading and filling out our Check-in forms ahead of time.

Please click the links on the right to download our intake forms.

Special Forms

Cosmetic Only

If you are visiting us for a cosmetic procedure or consult with our aesthetician, please feel free to download and fill out our Cosmetic Intake and Financial Policy form ahead of time.

Please click here to download the form.

Medical Records Release

If you wish us to release any of your medical records, please download and fill out our Authorization for Use and Disclosure of Protected Health Information form.

Please click here to download the form.

 

Location

Medical Dermatology Associates of Chicago
363 West Erie Street, Suite 350
River North

Chicago, IL 60654
Phone: 312-995-1955
Fax: 312-995-1956

Office Hours

Get in touch

312-995-1955