AFFZ11 MOHS Referral Form

MOHS Referral Form

Requesting Physician/Health Care Professional (HCP) Information:

Date of Request *

Date

Referring Clinician Name *

Prefix

First Name

Last Name

Phone Number *

Please enter a valid phone number.

Fax Number *

Please enter a valid phone number.

Patient Information:

Patient Name *

First Name

Middle Name

Last Name

Date of Birth *

Date

Phone Number *

Please enter a valid phone number.

Alternate Phone Number *

Please enter a valid phone number.

Street Address *

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Insurance *

Check type of skin cancer being treated by MOHS *

Basal cell carcinoma

Squamous cell carcinoma

Other

Please fax or email this completed form along with pathology report,
demographic face sheet, and color photo of the site (if available) to
262-754-4940 or mohs@affiliatedderm.com. If the patient is in your office and
you need immediate service, please call our office at 262-754-4488.