Dermatologist you would like to see *

Dr Todd Gunson
Dr Marc Lawrence
Dr Fergus Oliver
Dr Denesh Patel
Dr Chin-Yun Lin
Dr Bob Chan
Dr Jenny Chung
Dr Shaochen Liu

Surname (family name) *

Preferred name (if different from first name)

Your preferred pharmacy *

Please be as specific as possible (ie exact name and street address)

Have you seen this doctor within the last 2 years *

NHI (Hospital) number (if known)

Street address and postcode *

Postal address and postcode (if different from street address)

Next of kin (and relationship) *

Next of kin phone number *

GP practice name

Suburb at least please

Medical insurance? *

Southern Cross member? *

nib member? *

Who is your medical insurance provider? *

Southern Cross policy number *

Past skin problems *

Details please, include medications used, or enter “NIL"

Current or past medical problems and operations *

List, or enter “NIL"

Current medications *

Please list, or enter “NIL"

Medication allergies *

Please list, or enter “NIL"

Likely to need surgery? *

If you think there is a chance your skin condition will require surgery please answer “Yes

Select all that apply:

I have bleeding problems, excessive bruising, or post-surgical bleeding

I take blood thinners (aspirin, warfarin, clopidogrel, dipyridamol, dabigatran etc)

I take fish oil, ginko, vit E, ginseng, dong quai, feverfew, reservatrol, or garlic supplements

I have a pacemaker or implantable defibrillator

I have had joint surgery, artifical heart valve, or heart stent surgery in the last 12 months

I have had an infection following skin surgery

I take medications that suppress my immune system

I am a current smoker or past-smoker

How did you hear about us? *

Other source of finding us

Public funding eligibility *

Yes
No
Unsure

Due to health board requirements regarding laboratory tests and medication prescribing, we are required to ask this. If you are a NZ citizen or permanent resident the answer is Yes. If you are unsure, please contact reception for a list of eligibility criteria.

Reason for this consultation *

In your words, please briefly state the reason for your consultation. Specify if this is a lesion of concern or rash.

How long have you had this problem? *

Which parts of your body are affected? *

What makes it better? What makes it worse? *

How does the problem bother you? *

Is the problem worsening, stable, or improving? Please explain *

Have you seen a doctor for this problem? *

List treatments tried and if they are helped or not

Is there a family history of a condition similar to yours? If yes, specify *

Any other symptoms that you feel could be related? *

Please upload well-focused photos of the area(s) of concern below

Click to attach photo 1Max file size 4 Mb (4000 KB)

Click to attach photo 2Max file size 4 Mb (4000 KB)

Click to attach photo 3Max file size 4 Mb (4000 KB)

Click to attach photo 4Max file size 4 Mb (4000 KB)

Click to attach photo 5Max file size 50 Mb

I have received your email regarding remote consultations and consent to this

Remote/Virtual consultations may have limitations and potential disadvantages over tradition face-to-face consultations

Alert!