About the form
The form is designed to be printed, completed by hand or typed into the fillable PDF, and faxed as the first page of the referral to 905 625 5650. It fits on one letter size page. Images, pathology reports and other supporting documents go behind it as additional pages.
Using the form is optional. Many offices fax their EMR referral template instead, which is fine provided the fields listed below are present. Where an EMR template omits an item, for example the patient's second telephone number or an image flag, adding the DermCare form as a cover sheet fills the gap.
The PDF is in production and the download link above will be activated when it is available. Until then, please fax your own referral letter using the checklist on the how to refer page.
Fields on the form
The form is laid out in five blocks. Every field is listed here so that offices building an EMR template can match it.
1. Patient
| Field | Notes |
|---|---|
| Last name, first name | As it appears on the health card |
| Date of birth | Year, month, day |
| Sex | As recorded on the health card, for OHIP registration |
| Health card number and version code | Both are required. An invalid version code will cause the referral to be returned. |
| Primary telephone | The number we call first to book |
| Secondary telephone | A second number, or a contact person for a child or dependent adult |
| Email address | Optional |
| Mailing address | Street, city, postal code |
| Preferred language and interpreter needed | Tick box, with the language written in |
2. Reason for referral
| Field | Notes |
|---|---|
| Urgency | Tick one: urgent, or routine. Urgent referrals must state the reason. See urgent triage. |
| Clinical question | What you would like assessed or ruled out, in one or two lines |
| Presenting complaint and duration | Free text |
| Site and size | Body site, and approximate size in millimetres for a lesion |
| Change over time | Tick box for growing, bleeding, colour change, new symptoms, with free text |
| Image attached | Tick box, and the number of pages attached |
3. History
| Field | Notes |
|---|---|
| Treatments tried and response | Include over the counter products, with duration |
| Prior skin cancer | Tick box, with type and year where known |
| Immunosuppression | Tick box, with cause |
| Pregnant or breastfeeding | Tick box |
| Relevant comorbidities | Free text, for example inflammatory arthritis, diabetes, liver or kidney disease |
| Current medications | Free text, or "list attached" |
| Drug allergies | Free text |
| Results attached | Tick boxes for pathology, blood work, prior dermatology correspondence |
4. Referring provider
| Field | Notes |
|---|---|
| Name and designation | Physician or nurse practitioner |
| CPSO or CNO number | Registration number with the relevant college |
| OHIP billing number | Required for the consultation to be billed as a referred service |
| Office telephone and fax | The fax number is where the acknowledgement and the consultation report are sent |
| Signature and date | Required |
5. Primary care provider, if different
| Field | Notes |
|---|---|
| Name | The patient's family physician or nurse practitioner where the referrer is a specialist or walk in clinic |
| Fax number | A copy of the consultation report is sent here for continuity of care |
One patient per fax
Please send each referral as a separate fax transmission. Batched referrals for several patients under a single cover sheet are separated by hand at our end, which is where pages go missing.
After you send it
Receipt is acknowledged to the fax number on the form within a stated number of business days. The referral is then triaged by a dermatologist and the patient is contacted directly to book. The full process is described on the how to refer page, and questions about a referral already sent go to the referral desk on 905 625 5600.