New Patient Information Form

Which pharmacy (if any) would you like prescriptions sent to?

Community Services or Gold Card

YesNo

GP or medical centre you are registered with (type none if you are not registered)*

Transfer of Records - would you like us to request laboratory reports regarding previous skin surgeries or biopsies?

Yes, please request transfer of my recordsNo transferNot applicable

Name of Doctor previously seen for skin checks

Name of clinic previously visited for skin checks

Previous records are helpful but we are happy to see you without them. If you would like to request a copy of your records from The Skin Clinic, please email info@theskinclinic.co.nz and ask for a copy to be sent to you and admin@skinhub.co.nz

Would you like The Skin Hub to request a copy of your records from The Skin Hub on your behalf?

YesNo

Please list any medical conditions you have (type none if you don't have any)*

Please list any medication or supplements (including vitamins) you are currently taking (type none if you are not taking any)*

Please list any skin cancers you have had before (if any)

Have you or anyone in your family had a melanoma before?

Do you have any allergies*

YesNo

Please list any allergies (including medication, plasters, iodine, antibiotics, anaesthetic or other) and reactions you have had

What is your skin type

Very pale skin, always burns, does not tanFair skin, burns easily, tans poorlyDarker white skin, tans after initial burnLight brown skin, burns minimally, tans easilyBrown skin, rarely burns, tans dark easilyDark brown skin, never burns, always tans dark

Approximately how many times have you been sunburned in your life?

Approximately how many times have you been badly sunburned in your life?

0 - 1011 - 2021 - 50More than 50

Favourite sunscreen (if any)

Medical insurer (if any)

Southern Cross membership number (if applicable)

Southern Cross Information

We currently have one affiliated provider however appointment availability is very limited. This means it is likel

Southern Cross do not allow The Skin Hub to submit claims for routine appointments, including full skin checks.

For single spot checks, multi spot checks and surgeries, we can submit a claim on your behalf if you are seeing our affilated provider. If we are unable to make an appointment with our affiliated provider, you will need to pay for the appointment and make a claim directly with Southern Cross. We are happy to provide your receipt and any further information required.

If you have booked a skin check, do you consent to our medical professional checking your skin and taking digital photography to assess lesions of concern? Please note that you are welcome to view or request a copy of your images for your records at any time.*

YesNo

Digital photos will be taken during consultations. These are kept private, however they are sometimes shared with other medical professionals for referrals or teaching purposes. Do you consent to photos being shared for these purposes?

YesNo

If your appointment is a workplace skin check organised by your employer, which company do you work for?

Type a question

Would you like to receive occasional email updates from The Skin Hub?

YesNo

Is there anything else we should know about you? Please let us know if you have a pacemaker, needle phobia, prone to fainting, scarring, bleed easily or have had previous wound infections.

Do you have any cultural requirements that you would like us to be aware of?

Signature

If you are unable to sign above, please type your full name below:

Signed by

PatientAuthorised Person (Parent or Caregiver to sign if under 16 years)

Name of authorised Person with legal right to sign for this patient:

First NameLast Name

Relationship:

Date