Click on Calendar, type the year 'YYYY' and pick the month & date.
New Patient Registration


  Last name

  Mid initial

  First name
( )
*Address:
City :
Country
APT# :
Province/State :
PostCod/Zip :
YES! I would like to receive promotional emails or invitations to special events at Dermatology on Bloor.
()- -
()- -
()- - -
Email
Home
Business
Cell
Other # :
()- -
()- -
()- - -
I authorize Derm On Bloor to communicate with my Guardian on my behalf.
Patient's Signature :  

Medical History





Yes No What Type?
Yes No
Asthma
Hay fever
Eczema
Psoriasis
Basal Cell Carcinoma
Squamous Cell Skin Cancer
Melanoma
Other Skin Cancer
Other Cancer
Diabetes
High Blood Pressure
High Cholesterol
Liver
Kidney
Lung
Heart Disease
Lupus
Rheumatoid Arthritis
Multiple Sclerosis
Crohn's Disease
Ulcerative Colitis
Thyroid Disease
Vitiligo
Alopecia Areata
Depression
Headaches
Seizures
Eyes
Ears
Nose
Mouth
Blood Clots
Bleeding Disorders


Yes No
Yes No

Questions About Our Practice

Skin Care Products
Glycolic Peels / Microdermabrasion
Laser Hair Removal
BOTOX CosmeticTM
Eliminating Facial/Acne Scars
Facial Skin Tightening
Laser Tattoo Removal
Eliminating Leg Veins
BOTOXTM for Excessive Sweating
Removal of Moles/Skin Tags/Cysts
Reducing Wrinkles or crepe-paper-like skin
Photo-Rejuvenation (Improve Skin Tone/Texture/Colour/Pore size)
Body Skin Tightening (Abdomen, knees, arms)
Body Contouring (abdomen, arms, thighs, back)
Injectable Filler Materials :
Restylane/Perlane
Juvederm/Voluma
Radiesse
Sculptra
Selphyl (growth factor Injection for skin texture)

* I authorize Dr. to release medical information concerning my visit to the referring physicians. In some instances your care may be provided by another physician in the office.
*Signature :
Date :
(Your digital signature (full name) is as legally binding as a physical signature.)