Name *

First Name

Last Name

Address

Address 1

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City

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Do we have your permission to communicate with you via email?

Yes

Do you have medical insurance?

Yes

No

How did you hear about us?

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Referred by your doctor

Agreement *

I authorise the dermatologist or nurse my permission to obtain laboratory results and additional medical information from my GP, the laboratory or other specialist, which may be required to complete your consultation. The practice of dermatology involves an examination of the skin. In order to appropriately assess your condition the doctor or nurse may need to examine parts of your skin normally covered by clothing. Please feel free to request a chaperone if you require one. Consultations will cost between $250 and $450. There may be additional costs for procedures at the time of the consultation. External laboratory charges may be issued by the laboratory for non residents and for special tests. By signing this form you agree to pay the amount due and any costs associated with recovery of any money owing by you to SKIN Dermatology Institute.

I agree to anonymised photos being used by Dr Tallon, Dr Coutts or Dr Abbott for teaching or academic purposes

Consultations with the specialist dermatology nurse start at $110. There may be additional costs for procedures during the consultation. By signing this form you agree to pay the amount due and any costs associated with recovery to SKIN Dermatology Institute.