For referring providers

Refer a patient

Send a referral to Florida Institute of Dermatology in a few minutes. Fill in the form below, press send, and download a PDF copy for your records.

Fields marked * are required. Everything else is optional.

Patient

First name

Last name

Date of birth (DOB)

Phone

Insurance name

If the patient has no insurance, write Self-pay.

Insurance / member ID

If self-pay, write N/A.

Referring provider name

Practice / office name

Office phone

Office fax

Office email

Referring for

What you are referring the patient for.

Office

Pick the office closest to the patient. Specific provider requests can go in the notes below.

Office NPI

Fills in when you choose an office

Office address

Fills in when you choose an office

Goes to

Fills in when you choose a service

Reason for referral

Why you are referring the patient.

DOS / valid from

Optional

Valid until

Optional

Number of visits

Optional

CPT code(s)

Separate several codes with commas.

Diagnosis code(s) (ICD-10)

Separate several codes with commas.

Notes for our team (optional)

Sent over a secure connection. Please include only what the referral needs.