Dermatologist you are booked to see *

Your appointment date *

Surname (family name) *

Preferred name (if different from first name)

NHI (Hospital) number (if known)

Street address and postcode *

Postal address and postcode (if different from street address)

Next of kin (and relationship) *

NOK address and phone number *

GP practice name

Suburb at least please

Preferred pharmacy (name and street address please) *

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

Medical insurance? *

Southern Cross member? *

nib member? *

Who is your medical insurance provider? *

Southern Cross policy number *

What is the main reason for your appointment? *

Spots / moles
Skin check
Rash
Other

Please provide further details on your answer above *

How long have you had this problem? *

Days
Weeks
Months
Years

What parts of the body are affected? (choose all that apply) *

Scalp / face
Trunk
Arms / hands
Legs / feet

What makes it feel better and what makes it feel worse?

How much does the problem bother you? *

Not at all
A little
A lot
Very much

Is your problem: *

Worsening
Stable
Improving
Not relevant

Please explain your answer above

Have you seen a doctor for this problem? *

List all the treatments you have tried and if they helped or not

Please bring these treatments with you

Previous skin cancers? *

Please specify regarding your previous skin cancers

Is there a family history of a condition similar to yours? *

Please provide more information regarding this

Any other symptoms that could be relevant?

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 etc)

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 am a current smoker or past-smoker

How did you hear about us? *

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

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