Referring MDs

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*:

First Name*:

Your Email:

Date of Birth*:

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*: