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.

Marketing

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:

Phone

This field is for validation purposes and should be left unchanged.