Fortson Dermatology & Skin Care Center Anchorage Alaska

Need an Appointment or More Information About Our Services?
The health and effective treatment of your skin is our primary concern. For that reason, we are not able to provide specific medical advice by email. Please call us so that we may discuss the specific questions or skin concerns you may have.

To ensure your privacy, we will contact you by phone to answer your question or to schedule an appointment time that best fits your needs. Please include a daytime phone number with your inquiry. We return most calls within 24 working hours. If you have an urgent need, please call us at 907.563.3204.

I would like:
To Schedule an Appointment
A Gift Certificate
More Information about Services

(Please give us your name and contact information, and complete the appropriate section on this form with more details about your request).
** Required fields

About You

First Name**

Last Name**

Mailing Address

City

State

Zip

Email **

Daytime Phone Number xxx.xxx.xxxx (** required so we may contact you)

Best Time to Call (between 9:00 am and 5:00 pm weekdays)

AM PM

Cell Phone Number xxx.xxx.xxxx

Best Time to Call (between 9:00 am and 5:00 pm weekdays)

AM PM


News & Updates
	Please add me to your email list for specials, new services and products, and discounts. (We will not share your name or email address with anyone else.) *Please ensure you have entered your email address above.*

Appointment
I would like to schedule an appointment
(Monday to Friday: 9:00 am – 4:30 pm)
Day(s) of week that are best M T W Th F

Time of day that is best
AM PM

Please call me if there is a cancellation so that I may have an appointment as soon as possible.

Please tell us the reason for your appointment
Check as many as apply
Dermatology Services
	Acne/Acne Scarring	Brown/Red Spots
	Eczema or Dermatitis	Moles or Warts
	Psoriasis or Vitiligo	Rosacea
	Skin/Nail Infection	Skin Cancer/Screening
	Skin Growths	Other (describe below)
Other (limit 250 characters):


Cosmetic & Skin Care Services
	Botox®	Dermal Filler (Juvéderm™, Radiesse™, Restylane®)
	Crow’s Feet/Forehead Wrinkles	Excessive Sweating
	Fine Lines/Wrinkles	Fractional Skin Re-Surfacing
	Laser Hair Removal	Laser Skin Treatment
	Photofacial (IPL)	Skin Rejuvenation
	Spider Veins (Legs or Face)	Tattoo Removal
	Other (describe below)
Other (limit 250 characters):

Do you live outside of the Anchorage area or have a special need? Fortson Dermatology & Skin Care will work with you to accommodate special schedule requests or needs. If so, please let us know (limit 250 characters):

Gift Certificate
For birthdays, holidays or other special occasions, a gift certificate for skin care services or products would be a much appreciated gift. They are available in any amount, and you may use MasterCard or Visa.

Tell us the type of services and/or the amount you have in mind, and the date you would like to have the certificate:

Type of Service
Amount in $
Date Needed


More Information about Services I would like more information about your services (please describe-limit 250 characters):


How Did You Hear About Us? **
	Friend or colleague
	We appreciate the many referrals we receive. We would like to say “thank you” and will appreciate if you will provide us with a name
	Internet (Search or Website)
	Another healthcare provider ( Name)
	TV/Radio
	I’m already a client

	Anchorage Telephone Directory (Book or Online)
	White Pages (if selected please skip to end to submit)
	Yellow Pages (Please tell us which category):
	Physicians & Surgeons Guide:
	Alphabetical Listing Box Dermatology Dermatopathology
	Hair Removal Skin Care Tattoo Removal
	Mobile Mini (Please tell us which category):
	Physicians & Surgeons Guide:
	Alphabetical Listing Box Dermatology Dermatopathology
	Hair Removal Skin Care Tattoo Removal

	Mat Su Valley Telephone Directory (Book or Online)
	White Pages (if selected please skip to "Another healthcare provider" field)
	Yellow Pages (Please tell us which category):
	Physicians & Surgeons - MD:
	Alphabetical Listing Box Dermatology
	Hair Removing Skin Care Tattoos Removed

	Online Yellow Pages (Please tell us which category):
	Dermatology Tattoo Removal

	Other (please tell us) (limit 250 characters)

Important Privacy Notice
We cannot guarantee your privacy if you include sensitive information about yourself on this form or send information by email.

Confidentiality Notice
The information contained in this message is privileged and confidential, and intended only for the use of Fortson Dermatology & Skin Care Center. If the reader of this information is not a Fortson Dermatology staff member, you are hereby notified that this is not a waiver of privilege, and any dissemination, distribution or copying of this information is strictly prohibited. If you have received this information in error, please immediately notify Fortson Dermatology at 907.563.3204 to arrange for return or destruction of the information.

**I understand the privacy notice about this form.