Intake Forms for Dermatologists: Skin History, Sun Exposure Assessment, and Cosmetic vs. Medical Classification

By Daniel Akselrod · July 2026

A patient walks into a dermatology office wanting help with a mole that has been changing color and also asking about Botox for the forehead lines they noticed in last week’s Zoom call. These are two fundamentally different requests — one is a medical concern that may require a biopsy and insurance billing, the other is a cosmetic service paid out of pocket. The intake form that does not distinguish between them creates a billing problem, a documentation problem, and potentially a clinical problem before the patient ever sees the provider.

Dermatology sits at the intersection of medical necessity and aesthetic desire in a way that few other specialties do. A proper dermatology intake form must classify the visit correctly, capture a comprehensive skin history, assess sun exposure risk, review medications for interactions, document cosmetic treatment history, and handle the insurance complexities that make dermatology billing uniquely challenging.

Chief complaint classification: medical vs. cosmetic

The single most important field on a dermatology intake form is the one that classifies the visit as medical, cosmetic, or both. This classification is not a formality — it determines insurance billing, documentation requirements, prior authorization needs, and even which exam room the patient goes to in practices that separate medical and aesthetic services.

Medical dermatology covers conditions with a clinical diagnosis: acne, eczema, psoriasis, rosacea, skin infections, suspicious moles, skin cancer screening, and contact dermatitis. These visits are billed to insurance under medical CPT codes, and documentation must support medical necessity. If a patient presents with a rash and asks for a cosmetic consultation during the same visit, the chart must clearly separate the two — because the insurer will not pay for the cosmetic portion, and blending the documentation invites an audit.

Cosmetic dermatology covers elective treatments: Botox, dermal fillers, chemical peels, laser resurfacing, microneedling, and body contouring. These are not billed to insurance. Payment is collected at the time of service. The documentation requirements are different — focused on the patient’s goals, informed consent, and treatment planning rather than medical necessity.

Dual-purpose visits are common and complicated. A patient may want a suspicious mole evaluated (medical) and ask about laser treatment for sun spots (cosmetic) in the same appointment. Your intake form should capture both chief complaints separately and route each to the appropriate billing and documentation track. Practices that handle this well at intake avoid the billing headaches that come from trying to untangle a blended chart note after the visit.

Comprehensive skin history

Skin has a memory. Every sunburn, every biopsy, every chronic condition, and every treatment leaves a trace that affects current care. A thorough skin history at intake gives the provider context that a focused exam alone cannot provide.

Personal history of skin cancer. Has the patient been diagnosed with basal cell carcinoma, squamous cell carcinoma, or melanoma? When? Where on the body? What was the treatment — excision, Mohs surgery, radiation, immunotherapy? A patient with a history of melanoma requires a fundamentally different surveillance protocol than a patient presenting for a first skin check. Your intake form should capture the type of cancer, the date of diagnosis, the treatment received, and the outcome.

Family history of skin cancer. First-degree relatives with melanoma significantly increase the patient’s risk. A family history of atypical moles (dysplastic nevi) or melanoma changes the screening interval and the threshold for biopsy. This is not a question patients volunteer — they need to be asked directly.

Previous biopsies. Dates, locations on the body, and results. A patient who has had three biopsies in two years — all benign — is on a different surveillance track than a patient who has never been biopsied. A patient whose last biopsy showed atypical cells is on a tighter follow-up schedule. Without this history, the provider is making screening decisions without the data that should drive them.

Moles that have changed. The ABCDE criteria — Asymmetry, Border irregularity, Color variation, Diameter greater than 6mm, Evolution over time — are the standard screening framework for suspicious moles. Your intake form should ask whether the patient has noticed any moles that have changed in size, shape, or color, and where they are located. This question focuses the provider’s attention during the exam and ensures that the patient’s own observations are documented.

Chronic skin conditions. Eczema, psoriasis, rosacea, chronic urticaria, vitiligo, and severe acne each have long treatment histories. Capture the condition, its current severity, prior treatments (topical, oral, biologic, phototherapy), and what worked and what did not. A psoriasis patient who has failed three topical treatments and two biologics is in a different place than a psoriasis patient trying topical steroids for the first time.

Sun exposure assessment

Sun exposure is the primary modifiable risk factor for skin cancer, and a proper assessment goes well beyond asking whether the patient uses sunscreen. Your intake form should capture the cumulative exposure profile that drives the patient’s risk.

Fitzpatrick skin type. The six-point Fitzpatrick scale (Type I — always burns, never tans, through Type VI — never burns, deeply pigmented) classifies the skin’s response to UV radiation. This is a clinical classification, not a cosmetic one — it drives screening recommendations, treatment parameters for laser procedures, and skin cancer risk assessment. A Type I patient has a fundamentally different risk profile than a Type IV patient.

Occupation. An outdoor construction worker, a landscaper, a mail carrier, and a lifeguard all accumulate UV exposure that an office worker does not. Occupational sun exposure is chronic and cumulative, and patients often do not think of it as a risk factor because it is just part of their daily routine. Your intake form should ask directly about outdoor work.

Tanning bed use. Past and current. Indoor tanning before age 35 increases melanoma risk by 59%. Even patients who stopped tanning years ago carry the elevated risk from prior use. Your intake should capture whether the patient has ever used tanning beds, for how long, and how recently.

Sunscreen habits. Type (chemical or mineral), SPF level, frequency of application, and whether the patient reapplies during extended outdoor activity. This information helps the provider assess the patient’s UV protection behavior and provide targeted education rather than generic advice.

Geographic history. Years spent in high-UV regions — the Sun Belt, Australia, equatorial countries, high altitudes — contribute to cumulative UV exposure. A patient who grew up in Arizona and moved to Minnesota at age 40 still carries the UV burden from their first four decades.

Significant sunburn history. Blistering sunburns before age 18 are particularly significant — they approximately double the lifetime risk of melanoma. This is a specific question that patients often do not connect to their current dermatology visit, and it belongs on the intake form, not in a follow-up conversation.

Medication and product review

Dermatology medications interact with other medications, and skincare products interact with dermatology treatments, in ways that matter clinically. Your intake form needs to capture both.

Photosensitizing medications. Many common medications increase sensitivity to UV radiation: doxycycline (frequently prescribed for acne and rosacea by dermatologists themselves), hydrochlorothiazide (a common blood pressure medication), retinoids (both oral and topical), certain NSAIDs, fluoroquinolone antibiotics, and some antifungals. A patient on doxycycline who gets a chemical peel without the provider knowing about the antibiotic is at risk for an adverse reaction. Your intake form should ask about all current medications, not just dermatologic ones.

Current skincare products. Retinols, glycolic acid, salicylic acid, vitamin C serums, and prescription topicals all affect how the skin responds to in-office treatments. A patient using a prescription retinoid at home who receives a medium-depth chemical peel without the provider knowing may experience excessive peeling, hyperpigmentation, or scarring. Capture the patient’s daily skincare routine — both morning and evening products — so the provider can assess compatibility with planned treatments.

Topical allergies and sensitivities. Allergies to lanolin, fragrances, preservatives (parabens, formaldehyde releasers), latex, adhesives, and nickel are all relevant in dermatology. A patient allergic to adhesive tape needs a different wound closure method after a biopsy. A patient sensitive to fragrances needs fragrance-free product recommendations. Capture these at intake so they are part of every treatment decision.

Cosmetic treatment history and goals

For patients presenting with cosmetic concerns, the intake form should capture their treatment history and their expectations — both of which directly affect treatment planning and patient satisfaction.

Previous cosmetic treatments. Botox — when, where, how many units, results, and any complications. Dermal fillers — type (hyaluronic acid, calcium hydroxylapatite, poly-L-lactic acid), location, amount, results, and any complications (including migration, lumps, or vascular occlusion). Chemical peels — depth (superficial, medium, deep), product used, and results. Laser treatments — type (ablative, non-ablative, fractional, IPL), target (pigmentation, redness, texture, hair removal), and results. Microneedling — with or without PRP, results and complications. Capture the full treatment history because it determines what is safe and appropriate now.

Current skincare goals. Anti-aging, hyperpigmentation correction, texture improvement, acne scarring, redness reduction, pore size, skin tightening — each goal has a different treatment path. A patient whose primary goal is hyperpigmentation treatment will be disappointed if they receive a treatment optimized for fine lines. Your intake form should ask the patient to rank their top three concerns so the provider can build a treatment plan that matches their priorities.

Realistic expectations. This is a clinical assessment, not an intake form field — but the intake form can set the stage by asking the patient what outcome they are hoping for. A patient who expects Botox to make them look 25 again needs an expectations conversation before treatment, not after. Capturing their stated goal on paper gives the provider a documented starting point for that conversation.

Budget range. Cosmetic services are not covered by insurance. A patient who wants a comprehensive rejuvenation plan but has a $500 annual budget needs a different approach than a patient with a $5,000 budget. Asking about budget at intake is not presumptuous — it is respectful of the patient’s financial constraints and prevents the provider from building a treatment plan the patient cannot afford.

Insurance and referral documentation

Dermatology billing is complicated by the medical-cosmetic split, and your intake form needs to capture the insurance details that determine what gets billed and how.

Referral requirements. Many HMO plans require a referral from a primary care physician before seeing a dermatologist. If the patient has an HMO and does not have a referral, the visit may not be covered. Capture the insurance type at intake and flag HMO patients who need referrals so the front desk can verify before the appointment.

Prior authorization. Certain dermatologic procedures and medications require prior authorization from the insurer: biologic medications for psoriasis (adalimumab, secukinumab, ustekinumab), phototherapy, Mohs surgery (for some insurers), and allergy patch testing. Your intake form should capture the patient’s treatment history so the practice can initiate prior authorization before the patient arrives for treatment, rather than discovering the requirement during the visit.

Cosmetic services payment. Make it clear at intake that cosmetic services are not billable to insurance, even if performed during the same visit as a medical evaluation. Payment is due at the time of service. This avoids the uncomfortable conversation where a patient assumes their insurance covered the Botox because they also had a mole checked during the same appointment.

If you are building intake systems across a healthcare practice, the Healthcare Bundle includes dermatology alongside 20 other specialty-specific intake sets. For guidance on intake forms across medical specialties, see our guide on intake forms and insurance billing for healthcare.