Patient Referral

Patient Referral
Thank you for referring your patient to CutisCo Dermatology. We appreciate the opportunity to partner in your patient’s care.

To streamline the referral process, you may securely upload relevant referral documents. Completion of the form below is optional.
Upload Records

Accepted file formats: PDF, DOC, DOCX, JPG, JPEG, PNG, GIF, TIFF, and HEIC.
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Is this an urgent referral?*
Thank you for entrusting us with the care of your patient for this urgent dermatologic concern. Our team will reach out to the patient within 24 hours and will make every effort to schedule an appointment within the next three business days.
Skin cancer screeningSpot of concernAcneRosaceaEczemaPsoriasisHair lossDiscolorationMole removalCyst removalCosmetic concernsAge spotsOther
Preferred CutisCo Provider
Referring Provider
Provider Name

First NameLast Name
Referring Clinic
Phone Number
Format: (000) 000-0000.
Email Address
Patient Information
Full Name

First NameLast Name
Date of Birth

MonthDayYear
Phone Number
Format: (000) 000-0000.
Email Address
Guardian Information (if applicable)
Guardian Full Name

First NameLast Name
ParentLegal GuardianSpouseGrandparentOther
Guardian Mobile Phone Number
Format: (000) 000-0000.
Insurance Information
Is the patient insured?
Primary Insurance Company
At this time, CutisCo Dermatology does not participate with TRICARE Prime, and we apologize for any inconvenience.

Patients with TRICARE Prime are welcome to schedule as self-pay patients, with a deposit of $300 for new patient visits and $200 for follow-up visits collected at check-in and applied toward the cost of care. Services are billed according to TRICARE-allowable amounts. Because final charges depend on the services provided during the visit, any remaining balance will be refunded if charges are less than the deposit amount.

An itemized receipt can be provided after the visit for submission to TRICARE for possible reimbursement.
Secondary Insurance Company (if applicable)
Do you have an active Medicaid plan?
Medicaid ID
Should be Empty:

Patient Referral

Referring Provider

Patient Information

Guardian Information (if applicable)

Insurance Information