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Portland Dermatology Patient Referral Form
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Organization:
Mohs Surgery at Portland Dermatology
Portland Dermatology
Provider:
- Choose one -
Ken Lee MD
Date:
Reason for referral:
Patient Information
Patient Name:
Date of Birth:
Address:
State:
ZIP:
Phone: (preferred)
Phone: (secondary)
Does patient need an interpreter?
Yes
No
If yes, what language?
Insurance Information
Insurance Name: (Note: If patient does not have insurance, please type in Self Pay)
Insurance ID:
Insurance Group Number:
Policy holder name if different from patient:
Referring Physician Information
Referring Physician:
Clinic name (optional):
Phone:
Fax:
Contact name:
Contact e-mail:
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.
Disclaimer:
Please allow 1-2 business days for us to respond to your request. If your need is more urgent, please call our
office
and we will be happy to assist you.
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