New Patient History Form

Save time at your visit. Fill out your new patient health history in advance. Click here for the PDF form to print.

Completed Patient History forms can be faxed to 419.665.3632 or you may bring it with you to your appointment.


What to bring to your appointment

For all appointments, please bring the following:

  • Your most recent insurance card (click here for list of insurances we are in network with)
  • A government issued photo ID
  • A comprehensive list of your current medications  (and their doses and frequency)
  • An up-to-date allergy list
  • A list of creams or ointments or remedies you've tried (prescription or over-the-counter)
  • Your co-pay if you have one (a $10 service fee may be added if copays are not received on date of service)
  • For cosmetic treatments, payment in full must be made on date of service.


For surgery appointments, especially Mohs, please bring:

  • Something to read -- there can be wait time especially with Mohs surgery while we check the tissue margins to ensure there is no more cancer left to remove.
  • A driver -- especially if we are operating near your ear, eye, hand, or foot.  A driver is mandatory if you receive pain or anxiety medicine.
  • Consider bringing a snack if you are having Mohs surgery.

How to Prepare

In most cases, no pre-appointment preparation is necessary.  However, here are some general guidelines.

Surgery preparation:

  • Blood thinners:  Do not stop if physician recommended.  If you are on Coumadin, please know your last INR.
    High blood pressure:  Be sure to take your regularly scheduled blood pressure medicine.  
  • Food:  You may eat and drink as normal.  Have a healthy breakfast; and you may want to bring a snack.
  • Wait time:  If you are having Mohs surgery, Dr. Molenda checks 100% of the margin to make sure the skin cancer is out.  This can take 45 minutes or more of wait time; so please bring something to read.
  • Driver:  For skin cancers by your eye, a driver may be necessary if your eye needs to be patched.  Very nervous patients who receive optional relaxation medication (rarely needed) will also require a driver.


Laser procedures:

  • Sun protection: Sun avoidance and protection for 3-4 weeks prior to laser, and 3-4 months after. 
  • No tanning: We cannot safely treat tanned or recently sun exposed skin.  Once your pigment producing cells (melanocytes) are "activated" there are risks of dyspigmentation and blotchiness.
  • Cold sores:  We cannot proceed with any energy based device if you have actice cold sores on the treatment day.  Usually cold sores can be minimized or staved off with anti-virals.