PATIENT REGISTRATION & INFORMATION FORM

We are committed to providing our patients with the best care. To do this it is essential that your health record is kept up to date and accurate. Please fill in all applicable boxes

Given Name

Surname

Date of Birth

Sex

Male

Female

Occupation

Address

Street Address

City

Postal Code

Postal Address (if different from above)

Phone *

Email *

REMINDERS: I consent to being contacted with a reminder by SMS to maintain my appointments

YES

Next of Kin/Emergency Contact

Name
Address
Contact No.
Relationship to Patient

Medicare Card Details

Card No.
Ref No.
Expiry Date

DVA Card Holder

Card No.
Gold or White?
Expiry Date

Concession Card Holder

Card No.
Expiry Date

Name of Current Doctor and Medical Centre

Doctors working at this clinic are General Practitioners with special interest in Skin Cancer Medicine and Primary Care Dermatology. They are not Dermatologists. As a general guide, we recommend annual skin checks and we believe full body checks are best to enable skin cancers in their early stages to be identified Single Dropdownand treated. You will be asked to remove your clothing, but leave your underwear on. Some skin cancers especially melanomas may occur on skin that has never been exposed to the sun. The doctor will discreetly check the skin under your underwear. If you specifically do not want these areas checked please tell the doctor.

I consent to a full body skin check *

I consent to a partial body skin check of the following areas

I take full responsibility myself for areas I have not had checked

Signature of Patient

Clear

Date of Signature

PATIENT CLINICAL INFORMATION

__ Patient Name __

___ DOB ____

Do you have any allergies or are you sensitive to any drugs or dressings -in particular to medications, antiseptic solutions or sticking plasters?

YES

UNSURE

If Yes, details:

Current medications (Especially Aspirin or Warfarin)

SKIN CANCERS

Have you ever had a skin cancer diagnosed and treated by a doctor?

YES

UNSURE

If Yes, what type/s (Skin Cancer):

Have you ever had a malignant melanoma in the past?

YES

UNSURE

Do you have a history of melanoma in your immediate family?

YES

UNSURE

If Yes, who (melanoma):

Do you have a history of other skin cancers in your immediate family?

YES

UNSURE

If Yes, who (skin cancer):

_____________________________________________________________

Please notify us promptly of any changes in your contact details. Accurate contact details help us identify you and your medical records and allow us to contact you promptly about tests and results.

Signed by Patient or Guardian

Clear

Date

Name of Patient or Guardian