Covid-19 Application

Covid-19 Application Form for Appointment

Thank you for scheduling your appointment with DermaCare Brickell. In order to ensure compliance to new safety guidelines, we have implemented a new protocol that must be strictly adhered to.  The following is a list of actions needed prior to and during your appointment. This form must be completed and submitted the morning of your scheduled appointment.

* We are not accepting walk-ins. All patients must have a scheduled appointment. Our door will remain locked and will only be opened for scheduled patients. Please call or email to make an appointment.
* All patients with a scheduled appointment should arrive at your appointment time. Any early or late arrivals will be asked to wait outside until we are ready for you.
* Patients must come to their scheduled appointment alone. No kids or guests.
* Patients must wear masks to their appointment.
* Upon arrival, every patient will have their temperature checked and be asked to wash their hands. Following hand washing, we will provide you with a pair of disposable gloves.
* Please make an effort to pay with Apple or Samsung Pay as we are promoting payments without contact.
* Please reschedule your appointment if you are feeling ill or have any symptoms.
Please answer the following questions to the best of your ability.

*** Please note*** By filling out this form you agree to all the above mentioned policies and procedures. ALSO, by filling out this form, you acknowledge the contagious nature of COVID-19 and voluntarily assume the risk that you may be exposed to or infected by COVID-19 by attending Dermacare Brickell.

    Fever/Low Grade FeverChillsShortness of BreathCoughLoss of smell or tasteHeadacheBody Aches/Muscle PainTirednessSore throatNasal CongestionDiarrheaNone of These Symtoms