Online Consultation Form

Online Consultation Form
Full Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email Address
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Type of Consultation
Skin Lesion and Rash Disclaimer

I do not diagnose suspicious skin lesions. Any lesion of concern must be assessed by your GP or through my Map My Mole partnership service.
As a Nurse Practitioner, I also do not diagnose unknown rashes or unexplained skin conditions. These must be reviewed by your local GP.
I only treat benign conditions, superficial lesions, and cosmetic skin imperfections.
What Imperfection would you like treating?
How long have you had the imperfection?
Where is the imperfection?
Have you had this checked by the GP (required for mole or suspicious lesion)
If multiple imperfections, please give a brief description so I can give you estimate of the length of appointment time you will require
Do you have any medical conditions?
What information would you like to know?
Have you had medical Microneedling before? ( a minimum of 4 weeks is required between treatment)
Date of last microneedling (if applicable)

MonthDayYear
Date
Have you ever had skin cancer?
Do you take any blood thinners or anticoagulation medication
Do you take Accutane (Isotretinion) or use topically?(unsuitable if less than 6 months)
What are you looking to address with microneedling?
What further information do you require?
What information would you like to know?
General enquiry/other
Should be Empty: