Appointment Request – Clare Dermatology
Submit your details to request an appointment. Appointment requests are reviewed before confirmation.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number (WhatsApp-friendly)
*
Please enter a valid phone number.
Format: (000) 000-0000.
Reason for Visit
*
Medical Dermatology
Surgical Dermatology
Aesthetic Dermatology
Hair and Scalp
Wound Care
Other
Short Message / Concern
Virtual Appointment Policy & Consent
*
I confirm that I am 18 years of age or older, or am the legal guardian of the patient named above and authorized to request this appointment on their behalf.
I understand that a $200 BSD payment is required in full to confirm my virtual appointment. This payment is non-refundable, but I may reschedule at no cost with at least 24 hours' notice. Cancellations with less than 24 hours' notice result in forfeiture of the fee.
I understand that virtual consultations are limited in scope and that the dermatologist may require an in-person visit at their discretion before treatment can proceed.
Request Appointment
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