Provider Referrals

Waccamaw Dermatology is dedicated to providing your clients with the highest quality of care for all of their Dermatology and Mohs Surgery needs.

Referral Forms

• General Dermatology
• Mohs Surgery

1. Referring Provider*

   Urgent?*

   Yes

   No

   Phone number to referring provider*

   Fax number to referring provider*

   Contact*

   Patients Location PreferenceMyrtle BeachConwayLitchfieldDillonSumter

   Preferred Provider with location*

   Patient’s Name*

   Sex*

   SSN*

   Date of Birth*

   Address*

   City*

   State*

   Zip Code*

   Phone*

   Insurance Plan*

   Insurance ID Number*

   Reason*

   Submit

   Submit

   This field should be left blank
2. Referring Provider*

   Urgent?*

   Yes

   No

   Phone number to referring provider*

   Fax number to referring provider*

   Contact*

   Patients Location PreferenceLitchfieldMyrtle Beach

   Preferred Provider with location*

   Patient’s Name*

   Sex*

   SSN*

   Date of Birth*

   Address*

   City*

   State*

   Zip Code*

   Phone*

   Insurance Plan*

   Insurance ID Number*

   Reason*

   Submit

   Submit

   This field should be left blank