BJSCC New Patient Form

Welcome to the Bondi Junction Skin Cancer Clinic

Please help to us to help you by completing this form
Are you a new Patient?*

YesNo

Any Clinical Changes?

Has anything changed with your skin cancer history or contact details since your last visit?
Are there any immediate areas of concern you wish to discuss during your visit?

YesNo
Specifically, which areas?
Has your skin been examined by a doctor since we last saw you?

YesNo
CHANGES: If you have seen another doctor since your last visit?
Have any new allergies been uncovered?
Have any of your medications changed?
Have any relatives been diagnosed/treated for skin cancer?
Personal Detail Changes

If you have changed any of your details please advise
New or Changed Name

First NameLast Name
New Mobile Number
New Email
New Address

Street Address

Street Address Line 2

CityState

Post CodeCountry
Your Name*

First NameLast Name

Your Details
Salutation*
First Name*
Last Name*
Street Address
Suburb
Post Code
State
Mobile Phone*
Other Phone
E-mail*
Gender*

MaleFemale
Date of Birth*

DayMonthYear
Medicare Number
No.
Exp Date
Next of Kin Details
Next of Kin - Name
Next of Kin - Contact No.
Where did you hear about Bondi Junction Skin Cancer Clinic?*

Friend or FamilyWebsite or OnlineSignage or LocationDoctor ReferralOther ReferralOther

Your Background?

Please supply the following details
What is your family origin? (ethnicity)
How long have you lived in a sunny place like Australia?
Have you frequently spent large amounts of time outdoors for either work, play, or both?

YesNo
Occupation or Profession
What outdoor activity/s do you do at work?
If Yes, and roughly how many years have you done so?
What outdoor activity/s do you do in your own personal time?
Did you grow up in a rural area, a sunny place, or did you do a lot of outdoor activities?

YesNo
If Yes, and you have spent a lot of time outdoors, for how many years?

	Very Fair Type 1	Fair Type 2	Medium Type 3	Olive Type 4	Brown Type 5	Dark Brown Type 6
What Are You

Has Anyone in Your Family Had a Skin Damage Diagnosis?

Please supply the following details
Which Skin Cancers or Lesions are in your family?

MelanomaBasal Cell CarcinomaSquamous Cell CarcinomaSunspots or Actinic KeratosisPrecancerous MolesDysplastic NaeviOther
Which family members have had the above condition(s) ?
If you have a family history of Melanoma, has anyone in your family been diagnosed under 40 years old?

YesNo

Medications
Do you take any medications?
Allergies

Please supply the following details
Are you allergic to any of the following?

ADRENALINECHLORHEXIDINEDRESSINGSLATEXLIGNOCAINEXYLOCAINE
Are you allergic to any other prescription medications?
Is there anything else we might need to know about to look after you?

The Bondi Junction Skin Cancer Clinic now offers treatments that can prevent skin cancers, as well as others that restore and rejuvenate your skin.
Would you like to know more about these?

YesNo
Please Submit Your Form
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Welcome to the Bondi Junction Skin Cancer Clinic