Suburb at least please

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

Due to health board requirements regarding laboratory tests and medication prescribing, we are required to ask this. If you are a NZ citizen or permanent resident the answer is Yes. If you are unsure, please contact reception for a list of eligibility criteria.

Max file size 25Mb

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

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