Patient Information Form - Second Skin Dermatology

In order to provide a better and easier process or registration we have prepared this online registration form.Please fill in all the details required prior to your first appointment.

Title*
Patients Name*
First Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Phone (Home)
Phone (Work)
Phone (Mobile)
Best Email Address*
Date of Birth*
Gender*
Occupation*
Medicare Number - Number next to your name and Expiry
Name
First Last
Date of Birth
Date Format: MM slash DD slash YYYY
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Name of referring doctor
First Last
Name and address of GP (if not refering doctor)
Do you have a Pacemaker?*
Have you had heart valve or joint replacements?*
Are you taking any blood thinning medications?*
If Yes, please select.
What medications and/or creams are you using?*
Do you have any ALLERGIES?*
Please List (eg. Penicillin, Local Anaesthetic, Band-aids)
Please note: If a skin biopsy or an excision is performed, the tissue sample we be sent to pathology. The pathologist will bill you for this. Medicare rebates apply.
** Payment for consultation is required on the day. If this is inconvenient, please see our receptionist to book another appointment.** Thank you for your assistance.
I AGREE TO PAY ON THE DAY FOR THE CONSULTATION. I UNDERSTAND THAT EXTRA CHARGES APPLY FOR ANY PROCEDURES PERFORMED.
Signed ........................................................ Date ..........................
The Privacy Act prevents us from obtaining information regarding your medical history, previous medical records, test results, letters and other documents from health practitioners without your prior written consent
It also prevents us from releasing any information regarding your medical history, previous medical records, test results, letters and other documents to other medical practitioners without your prior written consent
If we do not have all your medical information, treatment and followup may be very difficult
Obtaining and/or releasing such information may often be required in order for the Doctor to make an informed decision regarding your treatment and may also be required during the process of booking you in for tests or procedures.
By signing this form, you give Second Skin Dermatology the right to store, obtain and/or release information regarding your medical history, previous medical records, test results, letters and other documents to/from other medical practitioners or hospitals.
Name ........................................................ Date of Birth ..........................
Signature ........................................................ Date ..........................
I agree and will sign:*
- To pay on the day of consultation
- The Privacy Consent Form
Email
This field is for validation purposes and should be left unchanged.