Dermatology Institute of Detroit

REFER YOUR PATIENT

If you’d like to refer your patient for Mohs surgery or other dermatologic surgery needs please complete the form below and click send button to send details to us.

Patient's Name: (required)

Patient's Phone Number (required)

Date of Birth (required)

Pathologic Diagnosis (required)

(Please attach pathology report)

Anatomic Site (required)
(Please attach photos)

Referral For:
Mohs Surgery
Excision
Biopsy
Other

Referring Provider (required)

Referral Notes

Thank you for entrusting us with your patient’s care! We aim to make this process as convenient as possible for both you and your patients…

REFER YOUR PATIENT (OFFLINE)

If you’d like to refer your patient for Mohs surgery or other dermatologic needs please download Refer Form , fille and submit the form via email or fax below.

Thank you for entrusting us with your patient’s surgical care. We aim to provide each patient with the highest quality, evidence-based surgical treatment and return them to your expert care.

REFERRAL FORM

EMAIL: refer@derminstitutedetroit.com

FAX: (313) 789-1671