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Skin Cancer Only

Register as a new patient at Skincanceronly

Save time - Register on line in advance!

We ask all new patients to attend 15 minutes before your appointment to complete medical history and background information.

As an alternative, we invite you to complete this background information for us below.

Our nurses will enter this information in advance of your appointment.

If you do not yet have an appointment with SkincanceronlyÂclick here.

If you have not read our pricing policy, click here.

If you have not read our appointment cancellation policy, click here.

Complete the following form to register as a new patient at Skincanceronly.

 

New patient registration form

Please complete this form to register as a new patient

Name*
What month is your appointment?
What day of this month is your appointment?
Day of week of your appointment?
What time is your appointment?
Home phone number
Mobile phone number
Reason for your attendance?
Are you a pensioner?

Do you have private health insurance?
Private health insurance number, if applicable
Level of private health insurance



Are you a Veterans Affairs patient?

Veterans Affairs number, if applicable
Referring doctor?*
I am on the following medications






List other medications you take regularly
List other past medical conditions
Date of birth DD/MM/YYYY*
Street address*
Suburb / Town*
Postcode
Name of next of kin
Relationship of next of kin to you?
Next of kin phone number
Your Medicare card number?
Expiry date of Medicare card MM/YYYY
Order in which your name appears on Medicare card?
Your occupation
List any allergies to medications or ointments
List any allergies to tapes or dressings
Comments
Submit
*Required