AFFZ11 MOHS Referral Form

MOHS Referral Form
Requesting Physician/Health Care Professional (HCP) Information:
Date of Request*

MonthDayYear
Date
Referring Clinician Name*

PrefixFirst NameLast Name
Phone Number*
Please enter a valid phone number.
Fax Number*
Please enter a valid phone number.
Patient Information:
Patient Name*

First NameMiddle NameLast Name
Date of Birth*

MonthDayYear
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

CityState / Province

Postal / Zip Code
Insurance*
Check type of skin cancer being treated by MOHS*

Basal cell carcinomaSquamous cell carcinomaOther
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.
Should be Empty: