Request a Consultation | Associates In Dermatology

Request Appointment Form

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<form-template><fields><field required="true" type="text" name="first-name" placeholder="First Name*" label="First Name"/><field required="true" type="text" name="last-name" placeholder="Last Name*" label="Last Name"/><field required="true" type="text" name="phone-number" placeholder="Phone Number*" label="Phone Number"/><field required="true" type="text" name="email-address" placeholder="Email Address*" label="Email Address"/><field required="true" type="select" name="select-location" label="Select Location"><option selected="true" value="">Select Location*</option><option value="Altamonte Springs">Altamonte Springs</option><option value="Apopka">Apopka</option><option value="Celebration">Celebration</option><option value="Clermont">Clermont</option><option value="Davenport">Davenport</option><option value="Dr. Phillips">Dr. Phillips</option><option value="East Orlando">East Orlando</option><option value="Hunters Creek">Hunters Creek</option><option value="Kissimmee">Kissimmee</option><option value="Mount Dora">Mount Dora</option><option value="Ocoee">Ocoee</option><option value="Poinciana">Poinciana</option><option value="St. Cloud">St. Cloud</option><option value="No Preference/Not Sure">No Preference/Not Sure</option></field><field required="true" type="checkbox-group" name="are-you-interested-in" label="Are you interested in:"><option value="Clinical Dermatology">Clinical Dermatology</option><option value="Cosmetic Dermatology">Cosmetic Dermatology</option></field><field type="checkbox-group" name="existingpatient" label="Existing Patient?"><option selected="true" value="Yes">Yes</option><option value="No">No</option></field><field type="date" name="date" label="Appointment Date"/><field type="select" name="appointment-time" label="Appointment Time"><option selected="true" value="8:00-8:30">8:00-8:30</option><option value="8:30-9:00">8:30-9:00</option><option value="9:00-9:30">9:00-9:30</option><option value="9:30-10:00">9:30-10:00</option><option value="10:00-10:30">10:00-10:30</option><option value="10:30-11:00">10:30-11:00</option><option value="11:00-11:30">11:00-11:30</option><option value="11:30-12:00">11:30-12:00</option><option value="1:00-1:30">1:00-1:30</option><option value="1:30-2:00">1:30-2:00</option><option value="2:00-2:30">2:00-2:30</option><option value="2:30-3:00">2:30-3:00</option><option value="3:00-3:30">3:00-3:30</option><option value="3:30-4:00">3:30-4:00</option><option value="4:00-4:30">4:00-4:30</option><option value="4:30-5:00">4:30-5:00</option></field><field type="text" name="insurance" placeholder="Health Insurance" label="What is your Health Insurance?"/><field required="true" type="select" name="preferred-call-time" label="When is a good time to call?"><option selected="true" value="">Select One*</option><option value="Morning">Morning</option><option value="Afternoon">Afternoon</option><option value="Evening">Evening</option></field><field required="true" type="select" name="how-hear-from-us" label="How did you hear from us?"><option selected="true" value="">Select One*</option><option value="My Physician">My Physician</option><option value="Facebook Ad">Facebook Ad</option><option value="Google">Google</option><option value="Existing Patient">Existing Patient</option><option value="Other">Other</option></field><field type="textarea" name="comments" placeholder="Enter any comments or questions that you may have here..." label="Comments"/><field type="hidden" name="rendered-form" value="is_rendered"/></fields></form-template>

Upon submission, a representative will contact you during normal business hours to confirm your request.

Always call 911 for emergencies.

The best resource for skin care. Always good advice and care. Sarah Fellenz is great in care and service. The OTC cream she recommended is working very well to reduce/remove skin eruptions. Thank you to your wonderful staff.

— James T

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