Online Consultation Form

Online Consultation Form
Full Name*

First NameLast Name
Date of Birth*

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Date
Address*

Street Address

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Postal / Zip Code
Email Address*
example@example.com
Phone Number
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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?

Skin tag/multiple skin tagsCherry angiomas/blood spotsMilia (milk spots)Sun spots/hyperpigmentation/sun damageWartsVerrucaeSebaceous HyperplasiaBenign moles( previously diagnosed)Seborrhoeic keratosis or wartFibrous papuleFacial thread veins/spider naeviCholesterol spotsSyringomas
How long have you had the imperfection?
Where is the imperfection?
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?

YesNo
Do you take any blood thinners or anticoagulation medication

YesNo
Do you take Accutane (Isotretinion) or use topically?(unsuitable if less than 6 months)

YesNo
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: