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How can we help?

First Name

Last Name

Your Email

Your Phone

Your Media Affiliation

Deadline

Date of Birth

Are you contacting us on behalf of someone else? Are you requesting an appointment for someone else?

Are you a new Derick Dermatology patient?

How did you hear about us?

Which building's sign?

Which referral?

Other Person's First Name

Other Person's Last Name

Other Person's Date of Birth

Appointment Location or Telehealth Preferred Location(s) or Telehealth

Appointment Date and Time Preferred Appointment Date and Time

What would you like an appointment for?

Medical Dermatology (Describe Below)

Cosmetic Dermatology (Describe Below)

COVID-19 Antibody Testing (SARS-CoV-2 Serology)

Are you immunocompromised? Yes No

Some people do not generate detectable IgG antibodies due to underlying immune disorders or immunosuppression. As such, this specific antibody test is not recommended for immunocompromised patients at this time.

Have you been fever-free (less than 100.4°F) for the last 72 hours? Yes No

Antibody testing is not intended for use in individuals with active symptoms. Please seek medical advice from your primary healthcare provider as soon as possible. Please call back when you have been symptom-free for 3 days, and we will schedule your antibody testing.

Have you experienced any of the symptoms listed? Yes, I am currently experiencing symptoms Yes, I had symptoms that began less than 10 days ago but are now resolved Yes, I had symptoms that began more than 10 days ago but are now resolved No, I have not experienced symptoms

Have you had any contact with any confirmed or suspected cases of COVID-19? Yes, more than 10 days ago Yes, less than 10 days ago No

Have you traveled or had contact with anyone who has traveled to any countries classified as high-risk for COVID-19 exposure? Yes, more than 10 days ago Yes, less than 10 days ago No

Are you a healthcare worker or first responder? Yes No

You do not have current indications for antibody screening as you have low risk factors for a previous infection. If you would like to discuss further, please contact us by phone to discuss your specific situation.

Have you received a positive test result from a COVID-19 nasal swab test? Yes, it was more than 7 days ago Yes, it was less than 7 days ago No

COVID-19 Symptoms

Chills
Muscle Aches
Runny Nose
Sore Throat
Cough
Shortness of Breath
Nausea
Headache
Abdominal Pain
Diarrhea
Loss of Smell
Loss of Taste
New Rash
Feeling Weak or Lethargic
Lightheadedness or Dizziness
Seizures
Slurred Speech

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