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 24 hours before your first appointment. Do your best completing the form. There will an opportunity to discuss anything you are unsure about in your consulation.

Contact details

Name

Address

After entering your email address, please check your email for a verification code. Enter the code to continue.

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 and health cards

Please bring your Medicare card to your appointment. We need this number to process claims and rebates to your bank account. Please note that pathology providers sometimes charge more if we can't provide them with your Medicare number.

Your skin concerns

Please check with your private health insurer to confirm that they cover skin cancer screening examinations and/or photography, and the exact wording that they require on the invoice. Please mention this to our receptionist when you arrive for your appointment.

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

Skin cancer risk factors

Note: Even if you're attending Spot Check Clinic for concerns other than skin cancer, it's important for us to detect and safely treat cancers whenever possible. This means we need to assess the skin cancer risk profile of all our patients. 

Occupational risk factors

Family History

Note: Melanoma is a potentially serious form of skin cancer, always treated by surgical removal. If a parent, brother, sister, son or daughter has had a melanoma, your risk of developing melanoma is above average.

For other types of skin cancer (for example, basal cell carcinoma or squamous cell carcinoma), or if you don't know, answerNoto this question.

Note: Non-melanoma skin cancers include basal cell carcinoma and squamous cell carcinoma. These are by far the most common types of skin cancer, affecting most Australians by the age of 70. If a family member has had a skin cancer and you don;t know what type of skin cancer it was, answer Yes to this question.

Ultraviolet exposure

Skin type

Aesthetic concerns and history

Rosacea concerns and history

Optional question 1: Clinical photography

Optional question 2: How did you hear about Spot Check Clinic?

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 without cancelling at least 24 hours earlier

• book a total body mole mapping appointment and then decide not to have this service performed 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 your risk of having skin cancer now and in future and to develop a suitable plan for skin cancer screening and prevention.

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.