Referral Fax Form

FAX REFERRAL REQUEST

Date:

Number of Pages:

Fax this form to make a referral

Referring Physician:

Phone:

PCP (if different from referring):

Patient Name:

Patient Home Phone:

Patient Cell:

Diagnosis (required):

REQUIRED PATIENT INFORMATION

Copy of referral

Copy of patient insurance card and demographics

Copy of last chart notes

Copy of pathology report (if applicable)

NOTE: All information is needed to schedule an appointment

Special Instructions:

Contact Person:

Title:

Phone:

Fax:

Appointment Date:

Time:

Contact Person:

Board Certified Dermatologist providing:
General Dermatology│Pediatric Dermatology│Adolescent Dermatology│Phototherapy│Dermatologic Surgery

Thank you for referring your patient to our office.

Your information will be encrypted.

BOSWELL DERMATOLOGY

Phone: 559.439.3000, Referral Fax: 559.435.3229
www.boswelldermatology.com
6730 N. West Ave, Fresno, CA, 93711