Medical History Form


Below you will find our Medical History 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.

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