Downloadable Forms

To save time and make the process more convenient, you can fill out several forms at home before your appointment. Just click on the button below to print out a copy of the form on your printer, fill it out and bring it to your appointment.

Forms are available in Adobe Acrobat PDF format. Please click the link to download the appropriate form:

download New patient Registration

download Consent & privacy form

download Health History (Dr. Jazayerli, Dr Gandhi, and Jennifer Cunningham) (2 pages)

download Health History (Dr. Schultz)

download Practice Policies

download Patient Authorization To Disclose Health Information

download Authorization To Provide Treatment To Minors

Our Patient Portal


Educational Resources

To help you stay informed, listed below are some materials and videos that can help you identify and prevent skin cancer as well as links to the top dermatology websites.

Videos and Flyers

Sunscreen Information Flyer (pdf)
Self Exam and Body Mole Mapping Instructions (pdf)
How to apply Sunscreen (video)
How to perform a self exam (video)


American Academy of Dermatology
American Society for Dermatologic Surgery
Spot the Spot,
The Skin Cancer Foundation,
American Cancer Society,



Clear Skin Dermatology offers morning, evening and weekend hours for your convenience.
Contact our primary office at 630-443-8855 to schedule all appointments.

© 2017 Clear Skin Dermatology.