Referrals - Tareen Dermatology

To Our Referring Providers

At Tareen Dermatology, we value our collaborative relationships with referring providers and are committed to delivering the highest quality of care to our shared patients. If you are a referring provider, please fill out the below referral form and submit to our staff.

Referring Provider

Reason or Concern(Required)

Patient Name(Required)

Patient Phone Number(Required)

Phone Number*

Patient Date of Birth(Required)

Provider Name(Required)

Provider Preferred Contact

Referring Clinic(Required)

Referring Clinic Phone/Fax(Required)

Referring Clinic Address(Required)

Referring Clinic City(Required)

Referring Clinic State(Required)

Referring Clinic ZIP

Other Comments