Enter NIL if no GP

Suburb at least please. Enter NIL if no GP

This allows us to deliver your prescription electronically to your local pharmacy

Please bring these treatments with you

Details please, include medications used, or enter “NIL"

List, or enter “NIL"

Please list, or enter “NIL"

Please list, or enter “NIL"

If you think there is a chance your skin condition will require surgery please answer “Yes

Helps determine if you are likely to be eligible for public funding of blood and lab tests if required. For more information see: https://www.labtests.co.nz/wp-content/uploads/sites/2/2019/11/4.2-Test-funding-eligibility.pdf

Max file size 50Mb

You may attach your referral letter, photos, or relevant biopsy or lab test results

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