New Patient Registration - The Skin Cancer Practice

Name * Required
Title First Surname
Birth Sex * Required
Gender Identity * Required
Date of Birth * Required
MM slash DD slash YYYY
Ethnicity * Required
Country of birth * Required
Are you of Aboriginal or Torres Strait Islander origin? * Required
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Home Phone * Required
Mobile * * Required
Email * Required
Language spoken

Emergency Contact Name * Required
First Last
Address * Required
Street Address City State / Province / Region ZIP / Postal Code
Relationship to you * Required
Phone * Required
Next of Kin
- Same as Above
If different to emergency contact
First Last
Address
Street Address City State / Province / Region ZIP / Postal Code
Relationship to you
Phone

Name of last Doctor / Surgery * Required
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 * Required
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 * Required
Have any of your moles recently changed in size, shape or colour? * Required
If yes, please specify * Required
Are any of your moles or spots sore, itchy or bleeding? * Required
If yes, please specify * Required

Your History * Required
Have you had any skin cancers treated previously?
If yes, how was it treated? * Required
Please Specify
Have you had any blistering sunburn in the past? * Required
Have you ever used solarium in the past? * Required
Please select one of the following that best describes your skin: After 30 mins in the sun, do you * Required
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"? * Required
Are you on WARFARIN, CLOPIDOGREL- OR OTHER BLOOD THINNERS? * Required
If yes, please specify * Required
Do you have ANY IMPLANTED DEVICES in your body? eg Pacemaker, Defibrillator or Cochlear implant? * Required
If yes, please specify * Required
Are there any comments you might wish to add? * Required
If yes, please specify * Required