A dermatology referral form that carries what the skin cannot show

A dermatologist can see the skin. They cannot see last month.

The one thing a dermatologist does not need you for is looking at the skin. They will do that themselves, with better light and a dermatoscope, in about four seconds. What they cannot recover from the room, however long they look, is the history of the thing in front of them: how long it has been there, what it looked like before, what changed, and who noticed. A dermatology referral form is the only place that timeline exists — and most of the ones you can download are a scanned single-liner with somebody else's logo on it and a reason box big enough for three words. This preset is built around the two things the skin will not tell the specialist: the timeline, and exactly what has already been put on it. It opens already populated, every field and label is editable in plain language, and a printable PDF is ready as soon as the page loads. No account, no email wall. Most practices add their own letterhead before printing a pad from it.

• Built for HIPAA-compliant workflows

• Free to start — 50 patient actions each month

What a dermatology referral needs to carry

Who is sending the patient, what they observed, and what they are asking for — those three, done properly, are most of the job. So: patient name, date of birth and contact details, with insurance or payer details where your workflow includes them; the referring practice and clinician with phone, fax and NPI where one applies; and the referral date. Then the clinical entry, authored by the referrer. The site and side, described plainly — scalp, face, trunk, limb, hands, feet, nails or mucosa — with how many lesions or how widespread it is, and whether this is one specific spot or a distribution. When it was first noticed, by whom, and what has changed since, which is the field worth making required. Whether it itches, bleeds, weeps, hurts or has ulcerated. Personal and family history of skin cancer, previous biopsies, immunosuppression, current medications and allergies. The status of any previous pathology, recorded as available from a named source rather than as findings. The treatment already applied. And what the referrer is asking for: an opinion, a specific lesion looked at, or a condition needing a therapy they cannot start themselves.

What has already been put on it, and for how long

Here is the field with no real equivalent on any other specialty's referral. In dermatology, the treatment already given changes the appearance of the very thing being examined. Three weeks of a potent topical steroid on a fungal rash does not look like the same rash untreated. An emollient, an antifungal, a course of oral antibiotics, something a walk-in clinic prescribed, something a relative swore by — each of them modifies what walks into the dermatology clinic, and the specialist ends up reading an altered picture without knowing it was altered. So this preset gives the treatment history repeating rows rather than a single line: the product or medication, the strength where the referrer knows it, roughly when, how long it was used for, and what happened. Most referral pads leave a one-inch box for all of that and get back the word cream. Four rows and a helper line asking for brand names and approximate dates get you something the dermatologist can use before the patient has taken their coat off.

Edit it, then download exactly what you built

Rename the form, rewrite any label or helper text, mark fields required or optional, and add, duplicate, reorder or remove sections. A family practice that mostly refers suspicious lesions shapes this very differently from one whose referrals are mostly chronic rashes on failed treatment, and a dermatology practice putting a dermatologist referral form in front of the offices that send it work usually pre-fills its own address and fax details and trims the rest. Add rows to the treatment block if your patients arrive with longer histories. Cut the sections you never complete. A default PDF is ready the moment the page opens, and after any change a new PDF is generated from your current version, so the sheet you print or fax is the one you designed rather than a stale original — and reset restores the preset if an edit goes too far. It fits US Letter, prints cleanly in black and white and stays legible through a fax machine.

A four-physician family practice and the dermatology office it refers to

A four-physician family practice sends two or three dermatology referrals a week to the same office across town, and had been rebuilding the same document badly every time. They start here instead. The treatment block goes to four repeating rows, after the dermatology office pointed out that referrals kept arriving with the rash already treated and nobody at either end could say with what. The single duration box becomes three questions — when it was first noticed, by whom, and what has changed since — because first noticed by a spouse two summers ago is a different referral from first noticed last week. A records line is added for previous pathology, marked as available on request from a named lab. And the free-text impression box comes out altogether: the referring physicians had been writing a guess into it, and the dermatology office only ever wanted the observation and the timeline. One version, one printed pad, and the first appointment starts with a history instead of an interview.

Written by the referring clinician, read by the dermatologist

The clinical fields on this form belong to the referring clinician and are recorded exactly as written. Your front desk can complete the patient details, the payer block and the practice information, but the observation and the ask are the clinician's. What it does not do is worth stating plainly, because that is what makes it safe to complete in ninety seconds. It offers no diagnosis and no impression of what a lesion might be. It interprets nothing — not a lesion, not a biopsy, not a pathology report; where previous pathology exists it records that it exists and where to obtain it, never what it said. There are no photographs anywhere in this workflow: nobody photographs or uploads a lesion here, and the referring clinician simply describes what they observed in their own words. It rates no urgency, flags nothing as a suspected malignancy or as needing to be seen sooner, and decides who is seen first for nobody — the dermatology practice applies its own criteria on reading it. It determines no medical necessity and recommends no treatment. And because this builder is public, build your blank form here rather than typing in a real patient's details; it records interaction events only, and the labels, helper text and values you enter are never sent to analytics. DocRepute is HIPAA-focused and built for HIPAA-compliant workflows, with BAA availability planned at launch.

The referral is the handoff. The relationship starts after it.

Take the PDF today — it is free and nothing is held back. Where this gets more interesting is on the receiving side. DocRepute is a HIPAA-focused patient-experience platform for independent US practices, in early access ahead of launch, and a dermatology practice running it can have the referred patient answer their own history online before the visit, branched so a referred lesion is asked different questions from a chronic follow-up, with a treatment history block doing the same work it does here. The free tier gives 50 action credits a month, spent only when a patient completes a regular intake submission or a standard survey; creating, editing and publishing forms uses none, and the free tier has no AI. Paid plans add AI intake that asks practice-approved follow-up questions when an answer is thin, conversational surveys, and sentiment and topic analysis that turns three months of free text into themes a practice manager can read in one sitting. The dermatology specialty page has the fuller picture.