CheckMark Referral Platform

Patient

First Name

Middle Name

Last Name

Preferred Name

Health Number

Date of Birth

Sex

Phone

Email

Postal Code

Immunosuppressed

History of Skin Cancer

Provider

Name

Type

Billing Number

Phone

Fax

Email

Postal

Lesions

Comments

Referral Details

Date Received

Suspected Melanoma

Suspected NMSC

Changing Lesion

Referral Document

PDF only

Patient

First Name

Middle Name

Last Name

Preferred Name

Health Number

Date of Birth

Sex

Phone

Email

Postal Code

Immunosuppressed

History of Skin Cancer

Provider

Name

Type

Billing Number

Phone

Fax

Email

Postal

Lesions

Comments

Referral Details

Date Received

Suspected Melanoma

Suspected NMSC

Changing Lesion

Referral Document

PDF only

Previous Encounters

Basic Consultation

Send to patient

Send to referring provider

Fax

Dermatologists

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Additional Fax Numbers

Cover Note / Custom Subject (optional)

Applies to dermatologists and additional fax numbers above only — appended to each fax's subject line. Does not apply to any email recipient.

Email

Additional Emails

Send Delay

Instant 15m 30m 1h 2h 4h 8h 12h 24h

24 hours

Also download a copy to this computer

Only available for instant sends.

Tasks

Faxes

Referrals

Encounters

Select an Encounter

Manual Referral

Manual Encounter

Sign in

Tasks

Faxes

Referrals

Encounters

Select an Encounter

Manual Referral

Manual Encounter

Send Report

Search Filters

Add flag

Add task

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