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New Patient
Intake Form

Please complete the form below prior to your first visit. All information is kept strictly confidential and used solely to provide you with the highest quality care.

Personal Information

First Name *

Last Name *

Date of Birth *

Gender

Address *

City *

State / ZIP *

Phone *

Email *

Reason for Visit

Primary reason for your visit *

Please describe your primary concern

Medical History

Current medications (list all)

Known allergies

Previous skin conditions or skin cancer history

Other significant medical history

* Required fields. All information is kept strictly confidential. This form is for administrative purposes only and does not constitute a medical consultation.

Ready to Schedule Your Consultation?

Contact Exclusive Dermatology in West Palm Beach today. Dr. Rotter and the team are here to help you look and feel your best.

Call (561) 561-SKIN (7546) Request Online

500 S. Australian Ave, Suite 205 • West Palm Beach, FL 33401 • Mon–Fri: 9am–4pm

New PatientIntake Form

Personal Information

Reason for Visit

Medical History

Ready to Schedule Your Consultation?

New Patient
Intake Form