M. Dika Dermatology, SC

Request an Appointment

Complete the form below and our team will reach out to confirm your appointment

Patient Information

Are you a new or returning patient? *

New Patient Returning Patient

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Full Legal Name * Please enter the patient's full name.

Date of Birth * Please enter date of birth.

Sex * Please select a sex.

Email Address * Please enter a valid email.

Cell Phone * Please enter a phone number.

Insurance Information

Do you have insurance? *

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Please note: A member of our team will contact you prior to scheduling to discuss payment options and obtain payment information. Appointments are subject to availability and eligibility verification.

Reason for Visit

Chief Complaint * Please describe your reason for visit.

Preferred Location

Burlington 1050 Milwaukee Ave, Suite 101
Burlington, WI 53105

Glendale 2500 W. Silver Spring Dr.
Glendale, WI 53209

Kenosha · Opening July 18, 2026 4824 Green Bay Rd
Kenosha, WI 53144

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Please note: Submitting this form is a request for an appointment — it is not a guarantee of scheduling. All requests are subject to availability and insurance eligibility verification. A member of our team will contact you once we have reviewed and verified your information.

By submitting this form, you confirm that the information provided is accurate. Your information is transmitted securely and used only for scheduling and care purposes.

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Thank you — we've received your request!

This is not a confirmed appointment. Our team will review your information, verify eligibility, and reach out to confirm scheduling.

Questions? Call or text us at (414) 433-7692.