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.


Heartland Dermatology utilizes a secure server and network and we take great efforts to ensure the security and safety of your information after it is received. Unfortunately we do not have control over the network that is utilized by our patients. In the event you are unsure about your connection being secure, please feel free to print the forms and either mail or fax after completion.  

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 5 locations in Salina, Hays, Great Bend, Newton & Dodge City.

5 convenient locations across Kansas.

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

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

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

NEWTON OFFICE
P 316 282 8100
F 833 886 9695
700 Medical Center Dr.
STE 101, Newton, KS 67114

DODGE CITY OFFICE
620 225 8865
620 225 8866
2020 Central Avenue
Dodge City, KS 67801

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 5 locations in Salina, Hays, Great Bend, Newton & Dodge City.

Office Hours

Salina Office Hours: 8:00AM to 5:00PM Monday thru Friday. Great Bend Office Hours: 8:00AM to 5:00PM Monday thru Thursday. Hays Office Hours: 8:00AM to 5:00PM Monday thru Thursday and 8:00AM thru 12:00PM on Friday. Newton Office Hours: 8:00AM to 4:00PM Monday & Thursday. Dodge City Office Hours: 8:00AM to 5:00PM Monday thru Thursday.

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