Patient Information Form


Below you will find our Patient Information Form. You can either fill it out online and submit it electronically before your appointment, or you can click here to print it so that you may fill it out and bring it to your appointment. This is a secure form and is HIPAA Compliant.

Start your journey.


We are standing by to help you achieve your unique skin goals. Please contact us using our contact form, or give us a call at any one of our three locations in Salina, Hays & Great Bend.

3 Convenient Locations

SALINA
785 827 2500
785 827 2515
828 Elmhurst
Salina, KS 67401

HAYS
P 785 628 3231
785 628 3174
2707 Vine | STE 10
Hays, KS 67601

GREAT BEND
P 620 792 3666
620 792 3667
1017-C Jackson Square
Great Bend, KS 67530

Get In Touch

Thank you for visiting Heartland Dermatology! Please contact us using our contact form, or give us a call at any one of our three locations in Salina, Hays & Great Bend.

Salina Office Hours: 8:00 AM to 5:00 PM Monday through Friday. Great Bend Office Hours:  8:00AM to 5:00PM Monday through Thursday. Hays Office Hours: 8:00AM – 5:00PM Monday through Thursday and 8:00AM through 12:00PM on Friday.

Copyright © 2017 Heartland Dermatology. All rights reserved. Website by Ultrabrand.com®.