CheckMark
Referral Form

You are a Doctor or Nurse Practitioner in BC. Please complete the CheckMark Referral form below and submit.

Referrer Details

Name First, Last

MSP #

Office #

(###)

###

####

Fax #

(###)

###

####

Office e-mail

Preferrable to fax

Date

YYYY

Patient Demographics

First Name

Last Name

Patient DOB

YYYY

PHN

Please ensure accuracy

Patient Phone #

(###)

###

####

Patient E-mail

Please ensure accuracy as patients will receive follow-up information by e-mail.

Patient Postal Code

Lesion location #1

https://anatomymapper.com/

Lesion location #2 (Optional)

Comments/Additional referral information

✦Note: All information collected in this form is kept strictly confidential.

FAQ

You can fax the referral form to
888-245-6275 or navigate to check-mark.ca to refer instantly online.
YES Have 1-2 specific moles of concern, are comfortable having images taken by a trained staff (not a dermatologist), want a faster or more convenient assessment
NO Multiple spots of concern (3+) , referral for full skin exam, spots located in intimate (breast or genital zones) or covered areas (in a tattoo or under hair)
Your colleague dermatologists at Spectrum Dermatology review your referral, a clinical questionnaire, clinical and dermoscopic photos before completing their report.
The report includes a likely diagnosis, differential, and recommended next steps. You can choose to manage the lesion yourself or refer to a local dermatologist or plastic surgeon. For referrals, we encourage you to attach the report to expedite the patient’s care.