Online Patient Referral Form

Referring Provider's Name(Required)

First Last

Credentials

M.D

D.O.

PA-C

APRN

Phone Number(Required)

Fax Number(Required)

Patient Information

First Name

Last Name

Email Address

Date of Birth(Required)

Month

Day

Year

Phone(Required)

Physician Preference(Required)

Dr. Rhinehart

Dr. Mollet

No Preference

Reason for Referral(Required)

Mohs Surgery

Skin cancer treatment

Skin lesion evaluation/removal

Skin cancer exam/screening

Blue light therapy for pre-cancers

Where on the body is the lesion?(Required)

Has this lesion been biopsied?(Required)

Yes

No

Please upload the following documents.

Patient Demographic Sheet(Required)

Max. file size: 300 MB.

Insurance Information(Required)

Max. file size: 300 MB.

Path Report (if applicable)

Max. file size: 300 MB.

Office Note (if applicable)

Max. file size: 300 MB.

Photos of lesion if possible

Taking a photo on patient's phone and asking to bring to the appointment is helpful.

Drop files here or Select files

Max. file size: 300 MB.

We know timely access to dermatology for skin cancer is an issue. We can schedule your patients with concerning lesions or confirmed skin cancers quickly. Patients can usually be seen within 14 days of the referral. We can work in urgent cases immediately.

Please indicate urgency.(Required)

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