Request An Appointment - Pariser Dermatology

To request an appointment, please fill out the form below or if you are a member of Pariser Dermatology FollowMyHealth Patient Portal, please login here to schedule an appointment. We will be in contact via email within 24 to 48 hours. Below you will be asked if you would like an in person visit or a live telemedicine visit. Not all patient concerns can be addressed via a telemedicine visit, such as a total body skin exam. If your problem is not addressable via telemedicine you will be asked to come in for an appointment.

Important Information
Name*
First Last
Date of Birth*
Date Format: MM slash DD slash YYYY
Address*
Street Address Address Line 2 ZIP Code
Phone Number*
Email*
Preferred Method of Contact
Insurance Carrier*
Insurance ID*
Insurance Subscriber's Name*
Secondary Insurance Carrier
Secondary Insurance ID
Secondary Insurance Subscriber Name
Appointment Type*
Reason for Appointment*
Preferred Office*
Additional Comments
Comments
This field is for validation purposes and should be left unchanged.

According to the HIPAA guidelines established by the Department of Health and Human Services, unencrypted email communication is not considered secure, but is permitted if the patient acknowledges and accepts the risks inherent with this form of communication. By submitting this form you authorize Pariser Dermatology to contact you via email regarding an appointment and acknowledge and accept this risk. If you do not wish to allow us to e-mail you please contact us at 757-622-6315 to schedule your appointment.

Important Information

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