Keloid Scar Enquiry

Welcome to our keloid scar assessment form.

Please complete all details in the form and we will be in touch within 1-3 business days.

Patient Details

First Name *

Last Name *

Email Address *

Phone Number *

DOB *

Suburb *

Details about keloid scar

Where is your keloid scar located? *

How long have you had your keloid scar? *

Have you seen your GP about your keloid scar? *

YesNo

Please provide details and history of your scar *

Upload an image of your concern *

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Medical History

Please list any medications you take *

Please list your medical history, including any medical conditions you may have *

Do you have any allergies? *

YesNo

Please enter your allergies *

Social Information

Occupation *

Smoking status *Never smokedEx-smokerSmokes occasionallySmokes regularly

By submitting this enquiry form, you agree to our Privacy Policy and acknowledge that any response received will not constitute medical advice, diagnosis, or treatment and will be for general informational purposes only. Responses should not be relied upon as a substitute for professional medical care. For any health-related concerns, please consult a qualified healthcare professional.  *

I consent to being contacted by phone, SMS or e-mail. *

Response to patient *

Appropriate for nurse driven combination treatmentShould see a dermatologist or GPNeeds to see a plastic surgeonAppropriate for Sarah SunNeeds to see CJCustom response

Custom Response *

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