Mohs Surgery | Skin Cancer Treatment

Skin Cancer Basics

Treatment Options

Repair Photos

Our Office

Dr. Naficy

Schedule a Consultation

If you would like to have Dr. Naficy assist you in evaluation, removal and/or reconstruction of your skin cancer, you may contact us by submitting this form. A member of our nursing staff will contact you at a convenient time and perform a telephone interview.

First Name:

Last Name:

Address:

City:

State:

Zip:

Email:

Day time phone:
Evening phone:

Do you have a primary care provider?

No Yes

Name:
City:

Do you have a dermatologist?

No Yes

Name:
City:

Have you seen or been referred to a Mohs specialist?

No Yes

Name:
City:

Location of the cancer:

Has a biopsy performed?

No Yes

By whom?

Do you know what type of skin cancer you have?

No Yes

Type:

Will you require help with accommodation/lodging?

No Yes

Are you expecting your insurance to cover all or a portion of the costs?

No Yes

Insurance company

How do you wish to be contacted:

Email Phone Either

Schedule your appointment with:

	Dr. Naficy
	Nursing Consult Consultation times are offered Mon thru Fri

Date and Time of consultation:

First Preference:
Date: Time:

Second Preference:
Date: Time:

Third Preference:
Date: Time:

Type of skin cancer treatments(s) you are considering:
(check all that apply)

Reconstructive surgery
Mohs surgery
Topical therapy
Surgical removal
Photodynamic therapy
Laser surgery

Additional comments:

How soon are you considering having the procedure(s) performed?

As soon as possible
I know exact time frame
Dates: From To
Within few weeks
Within few months
Unsure/Just considering my options

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