Patient Information Form
Thank you for for registering your interest with The Skin Hub. We currently have urgent single and multi spot check appointments available and are periodically opening up full skin check appointments when we spaces become available. Please complete the patient information form below and we will endeavour to contact you when we have an appointment available. This form must be completed for each patient prior to booking.
What type of appointment do you require
Full body skin check
Multi lesion check
Single lesion check
Surgery
Liquid nitrogen
Notes about the appointment you require
Name
*
Mr
Mrs
Miss
Ms
Dr
Mast
Prof
Other
Prefix
First Name
Middle Name
Last Name
Preferred Name (if different from above)
First Name
Last Name
Date of Birth
*
-
Day
-
Month
Year
Date Picker Icon
Gender
*
Male
Female
Other
Home Address
*
Street Address
Suburb
City
Post Code
Mobile Phone
-
Area Code
Phone Number
Mobile Phone
Home Phone
-
Area Code
Phone Number
Work Phone
-
Area Code
Phone Number
Email
example@example.com
Occupation
Ethnicity Details - Which ethnic group(s) do you belong to? Tick the space or spaces which apply to you
*
New Zealand European
Maori
Samoan
Cook Island Maori
Tongan
Niuean
Chinese
Indian
Other
Emergency Contact Name
*
Emergency Contact Relationship
Emergency Contact Phone Number
*
Phone or email
Back
Next
Which pharmacy (if any) would you like prescriptions sent to?
Community Services or Gold Card
Yes
No
CSC or Gold Card number
CSC or Gold Card Expiry date
-
Day
-
Month
Year
Date
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 records
No transfer
Not applicable
Name of Doctor previously seen for skin checks
Name of medical centre previously visited for skin checks
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 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
*
Yes
No
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 tan
Fair skin, burns easily, tans poorly
Darker white skin, tans after initial burn
Light brown skin, burns minimally, tans easily
Brown skin, rarely burns, tans dark easily
Dark 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 - 10
11 - 20
21 - 50
More than 50
Favourite sunscreen (if any)
Medical insurer (if any)
Please Select
None
Southern Cross
Sovereign
NIB
AIA
Unimed
AA
Other
Southern Cross membership number (if applicable)
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.
*
Yes
No
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?
Yes
No
If your appointment is a workplace skin check organised by your employer, which company do you work for?
Type a question
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
Patient
Authorised Person (Parent or Caregiver to sign if under 16 years)
Name of authorised Person with legal right to sign for this patient:
First Name
Last Name
Relationship:
Date
-
Day
-
Month
Year
Submit
Should be Empty: