Appointment Request

Request an Appointment
Thank you for your interest in CutisCo Dermatology. Please complete the form below, and a member of our team will contact you to assist with scheduling.
Patient Information
Full Name*

First NameLast Name
Date of Birth*

MonthDayYear
Mobile Phone Number*
Format: (000) 000-0000.
Email Address*
Guardian Information (if applicable)
Guardian Full Name

First NameLast Name
ParentLegal GuardianSpouseGrandparentOther
Guardian Mobile Phone Number
Format: (000) 000-0000.
Insurance Information
Will you be using insurance for this visit?*
To help make self-pay visits straightforward, a deposit is collected at check-in and applied toward the cost of your care. Because each visit is individualized, final charges may vary depending on the evaluation and treatment provided. If final charges are less than the deposit amount, any remaining balance will be refunded.
- New patient deposit: $300
- Follow-up visit deposit: $200
For more information, please review our self-pay policy here.
Primary Insurance Company*
CutisCo proudly welcomes patients with TRICARE Select as a participating non-network provider. You will be responsible for your applicable cost-share and any deductible required under your plan. Click here to learn more. Click here to learn more.
At this time, CutisCo Dermatology does not participate with TRICARE Prime, and we apologize for any inconvenience.

Patients with TRICARE Prime are welcome to schedule as self-pay patients, with a deposit of $300 for new patient visits and $200 for follow-up visits collected at check-in and applied toward the cost of care. Services are billed according to TRICARE-allowable amounts. Because final charges depend on the services provided during the visit, any remaining balance will be refunded if charges are less than the deposit amount.

An itemized receipt can be provided after your visit for submission to TRICARE for possible reimbursement, subject to your plan’s coverage and eligibility. Click here to learn more about how to file a claim with TRICARE.
Secondary Insurance Company (if applicable)
Do you have an active Medicaid plan?*
Medicaid ID*
About Your Visit
Skin cancer screeningSpot of concernAcneRosaceaEczemaPsoriasisHair lossDiscolorationMole removalCyst removalCosmetic concernsAge spotsOther
If you selected more than one concern, which concern is most important to you?
Preferences and Additional Details
Preferred Provider
Preferred Contact Method
GoogleFacebookNewspaperFlyersYelpFriend or FamilyReferred by another providerOther
Referring Provider Name*
I consent to being contacted by phone or text message regarding my appointment request. Standard message and data rates may apply.
Need urgent assistance? Please call 888-321-7170.
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Request an Appointment

Patient Information

Guardian Information (if applicable)

Insurance Information

About Your Visit

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