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Portland Dermatology Patient Referral Form
Mohs Surgery at Portland Dermatology
- Choose one -
Ken Lee MD
Reason for referral:
Date of Birth:
Does patient need an interpreter?
If yes, what language?
Insurance Name: (Note: If patient does not have insurance, please type in Self Pay)
Insurance Group Number:
Policy holder name if different from patient:
Referring Physician Information
Clinic name (optional):
Attach medical records here:
Medical Records such as:
Recent Chart Notes, Medical Photos, Problem List, Medication List, Allergy List, Recent Labs or CCD.xml file, if available, may be attached by clicking on the Browse button above.
MAX file size 10MB.
Please allow 1-2 business days for us to respond to your request. If your need is more urgent, please call our
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