REMOTE DERMATOLOGY SERVICE – FOR EXISTING PATIENTS

Please choose from the list of doctors below:

Dr. Jaggi RaoDr. Norman Wasel

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*:

MaleFemale

Alberta Healthcare Number*:

Preferred Email*:

Preferred Phone Number*:

Last visit to Rao Dermatology:

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?

What paperwork/form(s) do you wish for us to fill out? (NB: These may be scanned and sent to us securely below)

Other notes:

Pharmacy Name:

Pharmacy Location:

Pharmacy Telephone Number:

Pharmacy Fax Number:

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: Paperwork - [Your Full Name]".

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

Carefully select the image you wish to submit:

Statement of Authenticity*:

The information provided above is accurate, and I understand that missing or incorrect information will result in my teledermatology request NOT being answered, for it jeopardizes health and poses medico-legal liability.