Appointment Request — Charlotte Dermatology, P.A.

Please complete the form to request an appointment. A member of our team will contact you within one business day to schedule your appointment.

If this is an urgent request, please call our office directly at 704-364-6110.
If you have a life-threatening emergency, please dial 911.

Name

First Name

Last Name

Date of birth

Phone

(###)

###

####

Email

Address

Please include street address, city and zip code

Reason for visit

Are you a new patient?

Preferred provider

Preferred location

Insurance type