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Dr. Jayne Fortson, M.D. - Logo

Need an Appointment or More Information About Our Services?
The health and effective treatment of your skin is our primary concern.   For that reason, we are not able to provide specific medical advice by email. Please call us so that we may discuss the specific questions or skin concerns you may have.

To ensure your privacy, we will contact you by phone to answer your question or to schedule an appointment time that best fits your needs. Please include a daytime phone number with your inquiry.  We return most calls within 24 working hours.  If you have an urgent need, please call us at 907.563.3204.

I would like:
To Schedule an Appointment
A Gift Certificate
More Information about Services

(Please give us your name and contact information, and complete the appropriate section on this form with more details about your request).
** Required fields

About You  
First Name**
Last Name**

Mailing Address
City
State
Zip
Email **
Daytime Phone Number xxx.xxx.xxxx (** required so we may contact you)
Best Time to Call (between 9:00 am and 5:00 pm weekdays) AM  PM
Cell Phone Number xxx.xxx.xxxx
Best Time to Call  (between 9:00 am and 5:00 pm weekdays) AM  PM

News & Updates
Please add me to your email list for specials, new services and products, and discounts. (We will not share your name or email address with anyone else.)  Please ensure you have entered your email address above.

Appointment
I would like to schedule an appointment
(Monday to Friday: 9:00  am – 4:30 pm)
Day(s) of week that are best       M          T          W         Th         F

Time of day that is best
AM  PM

Please call me if there is a cancellation so that I may have an appointment as soon as possible.

Please tell us the reason for your appointment
Check as many as apply    
Dermatology Services    
Acne/Acne Scarring Brown/Red Spots
Eczema or Dermatitis Moles or Warts
Psoriasis or Vitiligo Rosacea
Skin/Nail Infection Skin Cancer/Screening
Skin Growths Other (describe below)
Other (limit 250 characters):
   
     
Cosmetic & Skin Care Services    
Botox® Dermal Filler (Juvéderm™, Radiesse™, Restylane®)
Crow’s Feet/Forehead Wrinkles Excessive Sweating
Fine Lines/Wrinkles Fractional Skin Re-Surfacing
Laser Hair Removal Laser Skin Treatment
Photofacial (IPL) Skin Rejuvenation
Spider Veins (Legs or Face) Tattoo Removal
Other (describe below)    
Other (limit 250 characters):
   

Do you live outside of the Anchorage area or have a special need? Fortson Dermatology & Skin Care will work with you to accommodate special schedule requests or needs. If so, please let us know (limit 250 characters):


Gift Certificate
For birthdays, holidays or other special occasions, a gift certificate for skin care services or products would be a much appreciated gift. They are available in any amount, and you may use MasterCard or Visa.

Tell us the type of services and/or the amount you have in mind, and the date you would like to have the certificate:

Type of Service
Amount in $

Date Needed

More Information about Services
I would like more information about your services (please describe-limit 250 characters):


     
How Did You Hear About Us? **  
Friend or colleague

 
  We appreciate the many referrals we receive. We would like to say “thank you” and will appreciate if you will provide us with a name
Internet (Search or Website)  
Another healthcare provider ( Name)

TV/Radio  
I’m already a client  
     
  Anchorage Telephone Directory (Book or Online)  
  White Pages (if selected please skip to end to submit)
  Yellow Pages (Please tell us which category):  
         Physicians & Surgeons Guide:
        Alphabetical Listing Box Dermatology Dermatopathology
        Hair Removal Skin Care Tattoo Removal
 

Mobile Mini (Please tell us which category):

 
         Physicians & Surgeons Guide:
        Alphabetical Listing Box Dermatology Dermatopathology
        Hair Removal Skin Care Tattoo Removal
     
  Mat Su Valley Telephone Directory (Book or Online)  
  White Pages (if selected please skip to "Another healthcare provider" field)
  Yellow Pages (Please tell us which category):  
 

       Physicians & Surgeons - MD:

        Alphabetical Listing Box Dermatology
        Hair Removing Skin Care Tattoos Removed
     
 

Online Yellow Pages (Please tell us which category):

 
        Dermatology Tattoo Removal
     
Other (please tell us)
(limit 250 characters)


Important Privacy Notice
We cannot guarantee your privacy if you include sensitive information about yourself on this form or send information by email.

Confidentiality Notice
The information contained in this message is privileged and confidential, and intended only for the use of Fortson Dermatology & Skin Care Center. If the reader of this information is not a Fortson Dermatology staff member, you are hereby notified that this is not a waiver of privilege, and any dissemination, distribution or copying of this information is strictly prohibited. If you have received this information in error, please immediately notify Fortson Dermatology at 907.563.3204 to arrange for return or destruction of the information.

**I understand the privacy notice about this form.

 

Photo
 
Fortson Dermatology & Skin Care Center, LLC | T 907.563.3204 | F 907.563.4283
2401 East 42nd Ave. | Suite 301 | Anchorage, Alaska 99508
Copyright © 2009, Jayne Fortson, M.D. All rights reserved.