Registration Form for Laser, Cosmetic and Injectable Treatments

Patient Details

First Name: *

Last Name: *

Date of Birth *

Age *

Gender *

Email Address: *

Phone Number: *

Full Address *

Postcode *

Occupation *

Details of Next of Kin (NOK)

First Name of NOK *

Last Name of NOK *

Relationship to the patient *

Mobile Number *

Please enter your Medicare Number including the reference number *

Please provide details of your GP *

Please indicate the MAIN reason for your laser or cosmetic consultation *

Please tell us the reason for your laser or cosmetic consultation *

Skincare Questionnaire

Are you currently having any laser treatments, chemical peels or other skin treatments? *

YesNo

Please elaborate *

Have you ever had any problems with skincare creams before? *

YesNo

Please elaborate *

Are you currently using tretinoin or any Vitamin A / Retinol creams? *

YesNo

Please elaborate *

Please describe your MORNING current skincare regimen in as much detail as possible *

Please describe your EVENING current skincare regimen in as much detail as possible *

Is there anything else you want to tell us regarding your current skincare? *

How would you best describe your skin type? *

NormalOilyDryCombination

Medical History

Please list any medications or other tablets/supplements you take. Type NA if you do not take any tablets. *

Please list any medical problems you may have. Type NA if you do not have any medical conditions. *

Have you ever had a cold sore? *

YesNo

Do you have any allergies to medications? *

YesNo

Please enter your allergies *

Are you pregnant *

YesNo

Are you breastfeeding? *

YesNo

Are you considering a pregnancy in the next 12 months? *

YesNo

Please insert any further information you would like to provide

Further information

How did you hear about us? *

I understand that by seeing a non-doctor cosmetic practitioner, I am not receiving a medical service, consultation, diagnosis or treatment and that I would need to see a GP or dermatologist if I am concerned about a medical problem or a skin lesion.
*

I understand that our dermal therapists and cosmetic nurses do not treat pigmented lesions (ie dark spots, moles, sun-spots), unless a clear diagnosis has previously been made and documented by a GP or dermatologist. A clearanceletter will be required from your doctor in such cases.
*

I have read the privacy policy and understand why my information is collected and how it is used. I acknowledge that I am not obliged to provide any information requested of me, but that failure to do so might compromise the quality of care provided to me. I understand that the contact details I provide will be used to communicate with me. *

I would like to receive informative communication relevant to skin health and dermatology.

FINISH BY SIGNING BELOW AND TAP SUBMIT

Please note that it may take a few minutes to submit this form.

Please do not leave or refresh this page until the page refreshes.

Signature - please use your finger or mouse cursor to draw your signature *

Clear