Patient Registration How did you first hear about Skin Matters SA? * Select an option Google Search Social Media Friend or Family Doctor Referral Drive by / Signage Other Please select how you heard about us Patient Consent Title * Title required First Name * First name required Surname * Surname required Date of Birth * Date of birth required Address * Address required Post Code * Post code required Medicare No * Medicare No required Expiry * Expiry required Phone No (H) * Phone number required Mobile * Mobile required Email * Valid email required Emergency Contact Emergency Contact Name * Emergency contact name required Emergency Contact Mobile * Emergency mobile required Regular GP Details Regular GP Name * GP name required Regular GP Clinic — Text * GP clinic required Skin History — Please Select if YES Previous skin cancer(s) * Yes No Family history of skin cancer * Yes No Use of solariums, active tanning * Yes No History of severe/blistering sunburn * Yes No Irregular moles/spots of concern * Yes No Any recent changes in moles/spots * Yes No Please select Yes/No for all skin history items i IntelliStudio Information IntelliStudio is an imaging tool designed to assist a Consultant’s diagnosis of pigmented skin lesions. IntelliStudio is regarded as a sophisticated and accurate aid to diagnosis of lesions however there is no guarantee of 100% accuracy of results with this procedure. We have the utmost respect for Patient’s privacy and these photographs will remain confidential within the Skin Matters practice. If your results indicate the need for excision of a lesion(s), do you give permission for a copy of Pathology results to be forwarded to Skin Matters SA? * Consent required I have read and understood the above information and hereby consent to undergo scanning of agreed skin lesion(s). * Consent required Please Sign the Form * ✕ Clear Signature is required Date * Date required
