Vulvovaginal disorders clinic referral form

If you have any questions or concerns, please e-mail referrals@meramecdermatology.com or reach me via the doctor's line at (636) 751-0995 option 1.

Thank you for your referral! To expedite your patient’s appointment, please complete this form and fax any additional pathology or lab reports to this HIPAA compliant number: (866) 783-0115, ATTN: VVD Clinic.
Referring provider name:
Referring provider office number:
Referring provider fax number:
Referring provider address:
Patient name:
Date of birth:

Month Day Year
Date
Patient phone:
Patient street address:
State:
Zip:
Patient's insurance (please fax a copy of the patient's insurance card if available to the fax number above):
If urgent, please indicate the need for urgent care:

Expedite (Less than 6 weeks) Routine (6-12 weeks) Urgent (Less than 4 weeks) Other
Chief complaint:
Suspected diagnosis:
What treatments has the patient tried thus far?

Topical steroids - high potency (i.e. clobetasol) Topical steroids - medium potency (i.e. triamcinolone) Topical steroids - low potency (i.e. hydrocortisone) Topical antibiotics Oral antibiotics Topical antifungals Oral antifungals Systemic immunosuppression (i.e. methotrexate, cyclosporine, biologics, etc.) Surgery Oral corticosteroids Cryotherapy Physical therapy referral Topical steroid sparing agents (i.e. Protopic, Eucrisa, Elidel) Other
Has a bacterial or fungal culture, viral pcr, or SureSwab been performed?

Yes No
If yes, what were the results?
Has a biopsy been performed?

Yes No
If a biopsy was performed, where anatomically was it done and what lab was it sent to for interpretation?
Vulvovaginal disorders clinic

Referral form
Should be Empty: