Fargo Center for Dermatology Provider Referral Form

Referring Providers
To Our Referring Providers

Fargo Center for Dermatology is committed to fostering strong partnerships with referring providers in order to ensure the highest quality of care for our shared patients.

To facilitate the referral process, please download or complete the electronic referral form below, and send any additional documentation to our office through one of the following:
- Fax: 701-478-8781
- Email: receptiondesk@fargoderm.com
- Electronic Submission: through our secure online system
Reason or Concern
Patient Full Name*

First NameLast Name
Patient Phone Number*
Phone Number*
Patient Date of Birth*

MonthDayYear
Date
Provider Name*
Referring Clinic*
Provider Preferred Contact
Referring Clinic Phone/Fax*
Please enter a valid phone number.
Referring Clinic Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Other Comments
Should be Empty: