REMOTE DERMATOLOGY SERVICE – FOR EXISTING PATIENTS

SCHEDULE A FOLLOW-UP APPOINTMENT:

Please fill out the secure form below.  You will be contacted shortly by the Rao Dermatology Team.  Based on our assessment of what you provide, we will do one of the following:

  • Contact you directly by secure email
  • Arrange for a remote session with you, or
  • Arrange for a face-to-face session with you
I am a patient of...

Please choose from the list of doctors below:

Administrative Information

If this form being completed by a Guardian/caregiver, please provide full name and contact information.

Guardian’s/Caregiver’s Full Legal Name:

Association to the Patient:

Patient’s Full Legal Name*:

Date of Birth*:

Gender*:

Alberta Healthcare Number*:

Preferred Email*:

Preferred Phone Number*:

Last visit to Rao Dermatology:

Current Problem

What is the skin-related condition we are treating?

What in-office treatment(s) did we do for you?

What medication(s) did we prescribe to you?

How is your condition right now?

Other notes:

Pharmacy Information

Pharmacy Name:

Pharmacy Location:

Pharmacy Telephone Number:

Pharmacy Fax Number:

Digital Image of the Current Problem

If you have issues uploading your images in the provided fields, please email attachments via email to telederm@raoderm.com with a subject line: "Telederm: Follow-Up - [Your Full Name]".

(NB: Scan or image must be under 8MB)

Carefully select the image you wish to submit:

Statement of Authenticity

Statement of Authenticity*: