New Patient Registration (Skin) - The Skin Clinic Fremantle

About You
Name*
First Last
Email Address*
Address*
Street Address Address Line 2 City State Post Code Country
Phone Number*
Date of Birth*
Please enter as dd/mm/yyyy

Date
Month
Year
Occupation*
Medicare Number*
Reference Number*
Expiry Date (Month)*
Expiry Date (Year)*
Name of Your GP
Questionnaire
Important: The Skin Clinic is operated by General Practitioners with a special interest, further training and additional qualifications in skin cancer medicine. It is important to be aware that no medical screening process can be 100% accurate. The screening for skin cancer is no exception. In particular, some skin cancers may have the appearance of benign moles and vice versa. Please assist us by answering the following questions carefully.
Have you had any non-cancerous moles removed?*
- Yes
- No
Please provide details:
Have you had any skin cancer treatment before?*
- Yes
- No
How were you treated?
- By cryotherapy (freezing)?
- By excision (cutting out)?
- By topical therapy (cream/lights)?
Please provide details:
Have any of your family members had any melanoma or other skin cancers removed?*
- Yes
- No
Please provide details:
Have you ever used a solarium (sunbed)?*
- Yes
- No
Do you have any medical conditions?*
- Yes
- No
Please provide details:
Are you allergic to any medication?*
- Yes
- No
Please list any medication you are allergic to:*
Are you taking any regular medication? (prescription medication, vitamins, supplements etc)*
- Yes
- No
Please list any medication you are currently taking:*
Do you have any raised moles or tags that bleed or get irritated by clothing?*
- Yes
- No
Please describe:
Have any spots on your skin changed recently in size, shape or colour?*
- Yes
- No
Please describe:
Important Information
As part of your skin check examination today, we shall be using a high definition imaging system to magnify the skin and make it easier for the doctor to see the detail in your moles/skin lesions. This system DOES NOT automatically record or save any images.

However, if there are any moles/skin lesions identified that are of short-term concern or that require longer term monitoring, your doctor will use the photography system to record and store images of those particular lesions for your medical records. We may also need to take photographs of any surgical procedure that may be required. These images will be stored securely in your medical record within the clinic and may be seen by other doctors within the clinic as part of our routine care. On occasion, it may be necessary to share these images with other health professionals involved in your medical care beyond our clinic, such as a pathologist or plastic surgeon.

Please indicate that you give your consent for us to record and store images of your skin by checking the appropriate box below.

On occasion, we may also wish to use certain images for teaching purposes of healthcare professionals such as medical students or post-graduate doctors. If you are happy for us to use your images in this manner, please indicate by checking the appropriate box below.

Any use of your images other than in your medical care and for teaching purposes is not included in this consent form and additional consent would therefore need to be sought for use of your images in any way other than that described above.
Your Consent - Images
I agree to the recording of and storage of my images for the purposes described above.
Your Consent - Use of images
I agree to the use of my images for teaching purposes as described above.
Parental Consent
I am under 16 years of age or unable to give consent
Privacy Policy*
I have read and agree to the privacy policy.
Offers and Updates
Please send me the Skin Clinic newsletter via email.
Patient Signature*
Name of Parent or Guardian*
First Last
Signature of Parent or Guardian*
Please indicate how you heard about The Skin Clinic Fremantle:
Information regarding our fees
Important: The Skin Clinic is a privately-billing clinic. The cost for a standard skin check is $100-140, depending upon the complexity of your skin and your medical history. If you hold a valid Medicare card, the out-of-pocket costs will be approximately $65 regardless of the length of your check. Any additional treatments or biopsies may incur a further cost. A single biopsy is $105, with an out-of-pocket cost of under $60. Aged Pension Card holders are billed at a reduced rate, whereby the out-of-pocket cost is approximately $12. Biopsies are at no additional out-of-pocket cost for pensioners. DVA patients (gold / valid white cards) are seen for a skin check with no out-of-pocket cost.
Name
This field is for validation purposes and should be left unchanged.

About You

Questionnaire

Important Information

Information regarding our fees