About YouName* First Last Email Address* Address* Street Address Address Line 2 City State Post Code Country AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarrussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Phone Number*Date of Birth*Please enter as dd/mm/yyyy Date Month Year Occupation*Medicare Number*Reference Number*12345678Expiry Date (Month)*010203040506070809101112Expiry Date (Year)*201920202021202220232024202520262027202820292030Name of Your GPQuestionnaireImportant: 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?*YesNoPlease provide details:Have you had any skin cancer treatment before?*YesNoHow 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?*YesNoPlease provide details:Have you ever used a solarium (sunbed)?*YesNoDo you have any medical conditions?*YesNoPlease provide details:Are you allergic to any medication?*YesNoPlease list any medication you are allergic to:*Are you taking any regular medication? (prescription medication, vitamins, supplements etc)*YesNoPlease list any medication you are currently taking:*Do you have any raised moles or tags that bleed or get irritated by clothing?*YesNoPlease describe:Have any spots on your skin changed recently in size, shape or colour?*YesNoPlease describe:Important InformationAs 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 consentPatient Signature*Name of Parent or Guardian* First Last Signature of Parent or Guardian*Please indicate how you heard about The Skin Clinic Fremantle:GP ReferralWord of MouthNewspaper AdvertGoogle / Web SearchOtherEmail CommentsThis field is for validation purposes and should be left unchanged.