Patient Registration Form & Health Questionnaire

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 *

Does the patient have a pension or health care card? *

YesNo

Please enter card number *

Please enter your Medicare Number including the reference number *

Please enter the expiry of your Medicare card *

Does the patient have private health insurance? *

YesNo

Is the referring GP the usual GP for the patient? *

YesNo

Who is the usual GP? *

Appointment Type

Is your appointment a TeleHealth appointment? (ie by telephone or video call) *

YesNo

At the time of your appointment, you will receive an e-mail (or sometimes an SMS) with a link to connect to your Zoom TeleHealth call.

Consulting Dermatologist

Please select the dermatologist you are seeing *

Dr Chris JalilianDr Jane LiDr Ann BoyapatiDr Vanathy Varathan

Referral

Do you have a referral from a GP or specialist? *

YesNo

Have you provided your referral to us already? *

YesNo

Please Upload Your Referral

If you are using your mobile device, and you have multiple pages to upload, we suggest taking photos of your referral now, then coming back to this screen and tapping Browse to choose the photos you have just taken.

If you are using your mobile device and your referral is a single page only, you can tap Browse now and take a photo of your referral.

If you are using your computer/laptop and you have your referral on file, please attach the referral directly by tapping Browse.

Please upload your referral here

Browse

Please take photos of your skin problem or upload existing photos here

1. Photos should be well lit. Natural lighting is best.

2. Hide “distractions.” Remove jewelry, clothing, busy wallpaper, etc.

3. Hold the camera steady with both hands.

4. Focus your photos by touching your phone screen. On most camera apps, you can pinch your fingers together to zoom in if necessary. Retake the picture if it's blurry.

5. Orient the camera parallel to your skin; do not angle up or down.

Photo 1

Browse

Photo 2 (optional)

Browse

Photo 3 (optional)

Browse

Photo 4 (optional)

Browse

FEE SCHEDULE

	Non-concession	Concession	Medicare Rebate with a valid referral from a doctor
Initial Consultation	$305	$290	$76.80
Subsequent Consultation	$210	$195	$38.60

If you are under 18 years of age, consent must be signed by a Parent/Guardian.

IN-ROOM PROCEDURE FEES

Should you require a procedure during your consultation, an additional out-of-pocket fee will apply. This can range from $50 - $750 depending on the complexity of the procedure.

The fee for a single standard biopsy ranges from $165 - $185 out of pocket.

As an example of a fee, if you were to have an initial consultation and a single biopsy;

the concession fee would be $500.00 with a medicare rebate of $123.00. This would leave you out of pocket $377.00
the non-concession fee would be $535.00 with a medicare rebate of $123.00. This would leave you out of pocket $412.00.

If you require more than one lesion or area biopsied, further fees apply.

CORTISONE INJECTIONS

Some conditions require treatment with cortisone injections. Should you require cortisone injections during your consultation, an additional fee of $210 applies. If you have a valid referral and Medicare card, you will receive a Medicare rebate of $39.45.

PATHOLOGY SERVICES

Please note that if you do not have a valid Medicare card, you will not receive any Medicare rebates and will incur additional charges from a pathology provider if tests are conducted for your consultation.

I have read the fee information and agree to pay the fee in full on the same day as the service. *

CANCELLATION POLICY

Appointments are in high demand, and your advanced notice will allow another patient to have access to that appointment.

I agree that I will need to call and cancel my appointment with at least 48 hours notice. *

WAITING TIMES

We endeavour to minimise waiting times for your appointment with the doctor. At times the doctor may be running behind and you may have to wait longer than usual. This usually occurs due to additional time required by our doctors to attend to patient needs. We appreciate your patience in such circumstances.

Medical History

Please indicate the reason for your referral *

Please tell us the reason for your referral *

Medications

Please list your medications here

Your Medical History

Please list any medical problems you may have here

Allergies

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

Have you ever had a skin cancer?

YesNo

Please provide further details *

Please add any further information you would like to provide

Further information

How did you hear about us? (you can select more than one option)

A brief introduction to your dermatologist

Dr Chris Jalilian | FACD

Dr Jalilian is an Australian trained consultant dermatologist and a Fellow of the Australasian College of Dermatologists (FACD). Dr Jalilian is drawn toward the medical, surgical and cosmetic diversity of dermatology.

In addition to his private practice, Dr Jalilian serves as a consultant dermatologist at Monash Medical Centre, Clayton and at the Skin Health Institute, where he consults in the melanoma follow up clinic.

Dr Jalilian acts as clinical advisor for his wife’s pharmacy, Skin Plus Compounding Pharmacy, co-located with Melbourne Skin & Dermatology in Rowville.

Dr Jane Li | FACD

Dr Jane Li is an Australian-trained Consultant Dermatologist and a Fellow of the Australasian College of Dermatology (FACD).

Dr Li has a special interest in a wide range of skin conditions including skin cancer, women’s dermatology, paediatric dermatology, eczema, psoriasis and acne. She has a particular interest in hair loss conditions (alopecia).

In addition to private practice, Dr Li also holds positions at the Skin Health Institute and St Vincent’s Hospital Melbourne.

Dr Li is committed to providing a holistic and caring experience. She speaks fluent English and Chinese (Mandarin).

Dr Ann Boyapati | FACD

Dr Ann Boyapati is a Consultant Dermatologist, Fellow of the Australasian College of Dermatology (FACD) and Fellow of the Royal College of Physicians in Ireland (RCPI).

She has a special interest in a wide variety of skin conditions and is passionate about improving both skin health and psychological wellbeing.

Dr Boyapati is also a Consultant Dermatologist at Alfred Health and Monash Health.

Dr Vanathy Varathan | FACD

Dr Vanathy Varathan obtained her MBBS with honours from the University of Jaffna Sri Lanka in 2002. She has more than 16 years of experience in dermatology and has trained extensively overseas and in Australia. In 2010, Dr Varathan obtained her MD in dermatology from the Postgraduate Institute of Medicine at the University of Colombo. She has been board certified by the College of Dermatologists in Sri Lanka since 2012.

In Australia, Dr Varathan qualified as a specialist general practitioner with RACGP. Most recently, Dr Varathan has successfully undergone her assessment with the Australasian College of Dermatologists and has received her full qualifications with the college.

With a broad interest in dermatology, Dr Varathan is highly motivated in dermatology and consults paediatric and adult patients and is competent in diagnosis and performing most skin cancer surgeries, treating psoriasis, eczema, acne, vitiligo, hair disorders, performing PRP injections, autoimmune skin conditions, infections, pigmentary disorders, pregnancy-related dermatology and immunobullous dermatoses.

Dr Varathan is fluent in English and Tamil.

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

I understand that whilst Melbourne Skin & Dermatology tries to reduce waiting times in the clinic, at times my dermatologist may run behind schedule and that I may have to wait in excess of 30-60mins to be seen. This usually ocurrs due to unexpected additional time that some patients may require to receive adequate care. *

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

I understand that masks must be worn in the clinic unless a valid exemption is held. A $2 charge will be applied if you require the clinic to supply you with a mask. *

FINISH BY SIGNING BELOW AND TAP SUBMIT

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Please do not leave or refresh the page until you receive confirmation of form submission.

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

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