Before you start...

This form requires you to upload two photos of each mole/skin lesion that you wish to have removed:

1. A close-up showing the mole from as close as possible while still in focus

2. A location photo, showing where the mole is located on your body or face

It's very important that all photos are in focus and well-lit, but without reflected light obscuring the view.

We strongly recommend that you take several photos of your mole before completing this form, so that you can make sure we have the best possible images. If your photos aren't clear enough for our doctor to assess, we'll ask you to re-send them, or if you prefer you can visit our clinic for a brief assessment appointment at least 2 days before your mole removal appointment.

Health Records Act 2001: Consent to collection of information

This form collects personal and health related information about you. By continuing to access this form, you give consent to Spot Check Clinic to collect this information. Please see our terms of service for more details on what information we collect and how it is managed.

If possible, please complete this form at least 48 hours before your mole removal appointment.

In compliance with recent changes to Medical Board guidelines, we are unable to offer cosmetic procedures to people under 18 yrs old. For cosmetic abnormalities causing significant adverse effects, we suggest you discuss the situation in a face-to-face consultation with your GP and consider referral to a plastic surgeon with experience in paediatric cosmetic concerns.

Please don't continue completing this form if you are under 18, or if you are completing the form on behalf of someone under 18. We apologise for any inconvenience.

Contact details

Name

Address

If you would like to access your clinical photos, pathology results, personalised information resources and online consultations, we need your permission to use your email address.

We send appointment recalls by email. If you prefer not to be contacted by email, we do not guarantee that you will receive a recall or reminder when your next appointment is due.

Spot Check Clinic does not send advertising materials by email.

Phone numbers

We use SMS to remind you of forthcoming appointments, request confirmation of appointments and to notify you when pathology results are available.

Spot Check Clinic does not use SMS for advertising or promotional purposes.

Emergency contact

Contact 1

Contact 2

Contact 3

Medicare

Most cosmetic procedures are not covered by Medicare and no rebate will be payable. But in some cases, the service will be covered by Medicare and you will receive a rebate. Please bring your Medicare card to your appointment so that we can process claims and have rebates paid to your bank account. 

If you don't have Medicare, there may be extra fees involved in your mole removal procedure.

In most cases, there are medical fees for

•  examination and assessment of your mole(s), and

• performing a biopsy to rule out skin cancer.
  

We have priced these fees equal to the amount paid by Medicare (in other words, so that there's no extra out-of-pocket expense). If you are not covered by Medicare, it's possible that these fees will be covered by other health insurance you hold, but we cannot guarantee that there will be no out-of-pocket expense.

The laboratory performing analysis of your skin specimen(s) will send you a bill for providing this service. We estimate that in most cases the fee will be $100-200 per specimen examined but we cannot give a precise estimate. If you have health insurance, it will normally cover at least part of the cost of the tissue examination performed by the laboratory. The fee charged by the laboratory and the amounts paid by health insurers are beyind our control.

Previous skin cancers and conditions

Item 1

Item 2

Item 3

General medical history

Medical and general health issues

Have you ever had any of the following medical issues or treatment?

Medications

Please list any medications, vitamins or supplements you are taking

Alergies and adverse reactions

Please list any medication allergies

Please list antiseptics, dressings and other skin irritants

Smoking

Our technique for removing moles and skin lesions is best for moles that are at least a little raised. Moles that are completely flat are best removed using other methods.

We should have enough information from the photos you've already sent to decide whether cosmetic removal is possible for your moles.

It might be difficult for us to remove more than 5 moles in one session, although we can often remove many tiny angiomas (small collections of blood vessels) in one visit.

We don't guarantee that all of your moles or skin lesions will be suitable for cosmetic removal, or that we will be able to removal them all at one visit.  Your doctor will discuss this with you when you attend your mole removal appointment.

This information helps us decide whether the mole you want to have removed might be a skin cancer. This would affect the type of procedure we would perform when removing your mole.

We sometimes share clinical photos so we can demonstrate to other patients and prospective patients the results of procedures. If you consent to share clinical photos now, you can withdraw consent later for any reason.

If you prefer not to answer this question, we will not use any of your clinical photos for educational or promotional purposes.

Late arrival, cancellation and no-show policy

Spot Check Clinic appreciates the value of your time, so we try to ensure that all appointments are on time. If you arrive late, we will do our best to provide a full and thorough service. As a courtesy to the next patient, however, your appointment will still finish at the originally scheduled time. This means that you have less time for your skin check and treatments. When you make an appointment at Spot Check Clinic, we reserve up to 60 minutes exclusively for you. If you cancel at late notice or simply don’t attend your appointment, someone else may miss out on the opportunity to have a skin cancer diagnosed and treated, and our practice incurs an expense. To recoup this expense, we may charge a cancellation fee of up to half the fee for the service you booked if you:

• cancel an appointment giving less than 24 hours’ notice

• don’t attend a booked appointment

• book an appointment for total body photography (mole mapping), cosmetic mole removal or BBL treatment and then decide not to have this service/treatment when you attend

We understand that sometimes late arrival or failure to attend may be beyond your control. In these circumstances we may waive the cancellation fee.

Your signature

Thank you for your answers. This information will be used to assess the suitability of your mole/skin lesion for cosmetic approval and allow us to deliver optimal treatment and follow-up.

By submitting this form, you certify that you have answered all questions truthfully and correctly to the best of your knowledge, and you understand and accept Spot Check Clinic’s policies.