Patient Resources
Patient forms
Before your appointment, please complete the following steps. It saves time at check-in and helps us give you the best care.
Four steps before your visit
- Step 1
- Fill out your health history in the patient portal — or fill in our forms on your computer or on paper.
- Step 2
- Read our Notice of Privacy Practices. You do not need to print it.
- Step 3
- Coming for a cosmetic visit? Fill out the cosmetic consultation form.
- Step 4
- Plan your route. Our Little Rock office is on the St. Vincent West campus.
Unfamiliar word? See our glossary of skin care terms.
Step 1: Complete your health history
Option A: Use the patient portal (recommended)
If you gave us your email address when you made your appointment, you will receive an email with directions for accessing your patient portal on EMA. In the portal, please complete your past medical history, past surgical history, medications and family history, and enter the pharmacy where you would like us to send your prescriptions.
Option B: Fill in these forms
If you do not have access to EMA, please complete all of the forms below and bring them with you to your appointment. You can type your answers on a computer, then save and print the forms, or print them and fill them in by hand. The forms work with screen readers.
You can read the full text of our office policies on the office policies page before you sign.
Need a form in another format?
We can provide large print, read the form aloud with you, or help you fill it out — free of charge. Call 501-817-3923 (TTY: 800-285-1131) or text 501-550-9095. You can also complete your history online in the patient portal, which works with screen readers and screen magnifiers.
Step 2: Read our privacy practices
Please read our Notice of Privacy Practices. You do not need to print this form.
Step 3: Condition-specific forms
For some visits, we need a little extra information to treat you best. If you are visiting us for the reason below, please complete the matching form.
Step 4: How to reach our Little Rock office
We are located on the St. Vincent West campus next to the Promenade at Chenal in west Little Rock, off Chenal Parkway.
- Driving west on Chenal Parkway: you will pass the UPS Store and Domino’s Pizza on your right and Perfect Vision on your left. At the next traffic light, turn left onto St. Vincent Way.
- Driving east on Chenal Parkway: you will pass the shops of the Promenade and McDonald’s on your right. At the next traffic light, turn right onto St. Vincent Way.
The St. Vincent West campus is on the left as you drive down St. Vincent Way from Chenal Parkway. We are in Pavilion 2 — the building on the left, with Cornerstone Pharmacy — as you pull into the campus. Our office is on the 3rd floor, Suite 300.
