Registration Form For Laser & Cosmetic Services

Patient Details

First Name: *

Last Name: *

Gender

Age *

Date of Birth *

Phone Number: *

Email Address: *

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 include brands and names of specific products

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? *Please include brands and names of specific products

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? *

Please ensure you come to your appointment with clean skin, free from makeup.

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 I can contact reception staff on 03 8595 4288 to discuss this further before completing this form. I understand that the contact details I provide will be used to communicate with me. *

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 Melbourne Skin & Dermatology's dermal clinicians 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 clearance letter will be required from my doctor in such cases. *

I consent to Melbourne Skin & Dermatology using photographs of my dermatological condition, taken or provided during my treatment, for educational purposes, ensuring that identifiable features and personal information are obscured or omitted to protect my privacy.

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

I acknowledge that I have read the information presented to me in this form and have no further questions. *

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

Todays date *