Last saved by: DSC Practice Manager

Welcome back to Dermatology Specialist Centre, Please make sure that you remove all make-up from your skin before seeing our dermatologist. This is a multipaged document so please be sure to fill out all forms. Please complete the entire form, circling information you believe has changed.  Thank you for your cooperation.

Personal Information
Salutation (please circle): DR / MR / MRS / MS / MISS / MSTR / REV / SR
First Name:			Surname: ______________________ 	
Preferred Name:			
Email Address:	_____________________________________________________
Street Address:  ____________________________________________________	
Suburb:		Postcode: _____	
Date of Birth:	Home Ph: _____________________________
Work Ph: 		 
Mobile:		Occupation:	____________________________
Regular GP: _________________________  GP Clinic _______________________
Other treating doctor/s and address : __________________________________________
Health Insurance / Benefits Information
MEDICARE CARD NUMBER    cccccccccc   REF:  c
EXPIRY:                                    cc/cc	
VETERAN AFFAIRS NUMBER:  cccccccccc 
PRIVATE HEALTH FUND NAME: ____________________________  FOR HOSPITAL ONLY (not extras)

TYPE OF COVER: ________________________________________

MEMBERSHIP NUMBER:	cccccccccc

EXCESS/CO-PAYMENT             $____________________________
Your Next of Kin
First Name:			Surname:      ________________________	
Phone:			Relationship: ________________________	
Medical Results (Please advise your doctor if you do NOT wish for photographs to be taken)
I give permission for my results to be sent via email or SMS? c YES  c NO
I give permission for clinical photographs to be taken and digitally stored.  For clinical management purposes these images may need to be shared with another doctor (e.g. if surgery was required for a skin lesion)  c YES  c NO
I give permission for clinical photographs to be used for teaching purposes (no identification used)? c YES c NO
I give permission for my results to be given to the person I have nominated below in my absence:
First Name: _______________ Surname: _______________ Contact:_____________
                                       ↓  ↓  ↓
PLEASE TURN OVER

 
Have you ever been treated for skin cancer?  Skin Cancer Surgery     c     Basal Cell Carcinoma                  c   Squamous Cell Carcinoma    c                 Melanoma                     c     Sunspots (Solar Keratoses)        c   
Family history of Skin Cancer- Please provide relevant information below:
____________________________________________________                                              
Have you used sunbeds in the past? (please circle) 	 					          YES   NO     
Have you used any of the following treatments previously?   
Efudix Cream       Aldara Cream       Picato Gel       PDT (photodynamic therapy)       Solaraze
Do you have any previous illness or medical condition we need to be aware of (tick below)?
High Blood Pressure      c 	Angina					c 	
Bleeding Tendency        c 	Diabetes					c 
Stomach Ulcer               c	Asthma					c 
Hepatitis or   HIV            c 	Joint Replacement			c 
Deep Vein Thrombosis   c 	Varicose Veins				c 
Currently Pregnant          c 	Heart Disease/Surgery		c 
Skin Cancer Surgery       c                         Poor or Delayed wound healing 	c
History Keloid Scarring    c                                         History of Arsenic Exposure		c        Other – Please provide relevant details:____________________________________  
Are you currently taking any medications or using topical creams (tick below)?
Aspirin / Cartia                 c 	Plavix					c 
Warfarin                           c 	Other Blood Thinners			c 
Arthritis Tablets                c 	Hormones or Oral Contraceptives	c 
Antibiotics                         c 	Fish Oil/Vitamins			c	
Need antibiotics before dental procedures							c	
Other – Please provide relevant details:  ____________________________________
Do you have any allergies that we need to be aware of when treating you (tick below)?
Local Anaesthetic                c 	Antibiotics				c 
Codeine                               c 	Topical Creams			c 
Tablets / Medication            c 	Wound dressing materials		c
Other – Please provide relevant details: ____________________________________

The responsible parent is to complete the following declaration if the  applicant is under 16 years of age.
   • I declare that the information I have supplied in this form is complete, truthful and correct in every detail.

Signature:	__________________________________________________________________

 Date:                   ________