Mohs Referral Fax Form

MOHS FAX REFERRAL REQUEST

Date:

Number of Pages:

Fax this form to make a referral for MOHS SURGERY

Referring Physician:

Phone:

Patient Name:

Patient Home Phone:

Patient Cell:

Diagnosis (required):

Basal cell carcinoma

Squamous cell carcinoma

Other

If other, specify (AFX, MFH, sebaceous carcinoma, melanoma in situ):

Anatomic site (as named on biopsy report):

REQUIRED PATIENT INFORMATION

Copy of pathology report

Photo of biopsy site (if available)

Copy of patient insurance card and demographics

Copy of last chart notes

NOTE: All information is needed to schedule an appointment

Special Instructions:

Contact Person:

Title:

Phone:

Fax:

Appointment Date:

Time:

Contact Person:

Following MOHS surgery, your patient will be directed to return to your office for routine dermatologic care.

Thank you for referring your patient to our office.

Your information will be encrypted.

BOSWELL DERMATOLOGY

Jared Lund, MD, FAAD, FACMS Fellowship-trained Mohs Surgeon through the American College of Mohs Surgery

Phone: 559.439.3000, Referral Fax: 559.435.3229
www.boswelldermatology.com
5701 N. West Ave, Fresno, CA, 93711