WESTMD SKIN CLINIC

FAX: 604-398-8125 | TEL: 604-398-8192
Surrey: 101-8386 120^th St (inside People's Pharmacy)
South Surrey: 3-3238 King George Blvd (icollab Healthcare)
PATIENT INFO
Name:

First NameLast Name
PHN #:
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Address:
Phone:
Format: (000) 000-0000.
Email*:
example@example.com
REFERRING PROVIDER
Physician / NP Name:
Billing #:
Phone:
Format: (000) 000-0000.
Fax:
REASON FOR REFERRAL
Type out your reason for referral (or select an option from below)
Inflammatory / Infectious Lesions
Tumor / Cancerous Lesions
PMHx / MEDICATIONS
(or attach chart)
WORKING DDx?
(helps triage referral)
URGENCY
Urgency
If semi-urgent, give reason below:
Please fax completed form to: (604) 398-8125
To ensure timely care, patients may be seen by the next available Skin-Focused GP. We will contact the patient with their appointment date and time. Dr. Dhandli is a GP with an interest in skin disorders, not a FRCPC dermatologist. Severe cases or those requiring complex/biologic therapy may be redirected. If you have not heard back from our clinic within five (5) business days, please re-send your referral.

If you wish to print / fax manually, click "Preview PDF"

If you wish to send to our clinic immediately, click "Submit"
Should be Empty: