Your appointment date *

Title

Surname (family name) *

First names *

Preferred name (if different from first name)

Date of birth *

NHI (Hospital) number (if known)

Street address and postcode *

Postal address and postcode (if different from street address)

Home phone number

Work phone number

Mobile phone number

Email Address *

Occupation

Next of kin (and relationship) *

NOK address and phone number *

Family doctor (GP)

GP practice name

Suburb at least please

Medical insurance? *

Southern Cross member? *

nib member? *

Who is your medical insurance provider? *

Southern Cross policy number *

nib policy number *

Past skin problems *

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

Current or past medical problems and operations *

List, or enter “NIL"

Current medications *

Please list, or enter “NIL"

Medication allergies *

Please list, or enter “NIL"

Likely to need surgery? *

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

Select all that apply:

I have bleeding problems, excessive bruising, or post-surgical bleeding

I take blood thinners (aspirin, warfarin, clopidogrel, dipyridamol, dabigatran)

I take fish oil, ginko, vit E, ginseng, dong quai, feverfew, reservatrol, or garlic supplements

I have a pacemaker or implantable defibrillator

I have had joint surgery, artifical heart valve, or heart stent surgery in the last 12 months

I have had an infection following skin surgery

I take medications that suppress my immune system

I have diabetes

I am a current smoker or past-smoker

Other source of finding us

Public funding eligibility *

Yes
No
Unsure

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.

Click to attach referralMax file size 25Mb

You may scan and attach your referral letter, and/or relevant biopsy or laboratory test results

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