Referring MDs

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We are pleased to offer you the convenient option to refer a patient for dermatological visitation with Dr. Jaggi Rao, without the need to fax or telephone.

The E-Referral Form below MUST be filled out by a Referring Doctor’s Office and MUST be authorized by a Canadian-licenced physician or nurse practitioner. The information you submit is secure and confidential, and will be forwarded only to Dr. Rao’s office for processing.

    Personal Information

    First Name*:

    Last Name*:

    Phone Number*:

    Your Email:

    Date of Birth*:

    Alberta Health Care Number*:

    Gender*:

    Once Scheduled, the following office should inform this patient of their appointment*:

    Referring Doctor Information

    Referring MD*:

    Referring MD's PRAC ID*:

    Referring MD's Office Phone*:

    Referring MD's Office Fax:

    Reason for Referral*:

    Upload Document #1 (Eg. Scan or Image under 2MB):

    Upload Document #2 (Eg. Scan or Image under 2MB):

    Authentication Information

    Name of person completing this form*:

    Statement of Authenticity*: