New Patient Registration - The Skin Cancer Practice

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This field is for validation purposes and should be left unchanged.
Name*
Title First Surname
Birth Sex*
Gender Identity*
Date of Birth*
MM slash DD slash YYYY
Ethnicity*
Country of birth*
Are you of Aboriginal or Torres Strait Islander origin?*
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Home Phone*
Mobile **
Email*
Language spoken

Name of last Doctor / Surgery*
When was your last Full Skin Cancer check?
- Less than 1 year ago
- More than 1 year ago
- More than 5 years ago
- Never had a skin cancer check
- Unsure
Skin History*
Do you have NEW MOLES or spots or do you (or others) have CONCERNS about any of your moles or spots?
If yes, please list*
Have any of your moles recently changed in size, shape or colour?*
If yes, please specify*
Are any of your moles or spots sore, itchy or bleeding?*
If yes, please specify*

Your History*
Have you had any skin cancers treated previously?
If yes, how was it treated?*
Please Specify
Have you had any blistering sunburn in the past?*
Have you ever used solarium in the past?*
Please select one of the following that best describes your skin: After 30 mins in the sun, do you*
Select all that apply
- Always burn, never tan
- Always burn, sometimes tan
- Sometimes burn, always tan
- Never burn, always tan
Is your skin known to KELOID or "over scar"?*
Are you on WARFARIN, CLOPIDOGREL- OR OTHER BLOOD THINNERS?*
If yes, please specify*
Do you have ANY IMPLANTED DEVICES in your body? eg Pacemaker, Defibrillator or Cochlear implant?*
If yes, please specify*
Are there any comments you might wish to add?*
If yes, please specify*