Medical GP Skin Consultation Registration

Contact Details
Name*
Prefix First Last
Preferred Name
First
DOB*
DD slash MM slash YYYY
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Telephone Number
Home Phone
Mobile Phone
Work Phone
Email
(An SMS reminder will be sent to your mobile 48 hours prior to your appointment)
Next of Kin
Name
First Last
Contact Phone Number
Relationship
Account Holder
(For patients under 18 years of age)
Name
First Last
Contact Phone Number
Relationship
Medical History
Please list current health conditions
Current medications / vitamins
Please list any allergies
Authorisation and consent to photography

At all times, skin lab BY WPRS respects patients’ rights to privacy and informed consent for procedures within the practice, including photographic records. I understand that these photographs form an essential part of my medical record, as well as my pre-treatment and post-treatment assessment.
I hereby consent to any necessary photography taken of me at Skin Lab by WPRS as part of my medical treatment. At all times, Skin Lab by WPRS respects patients’ rights to privacy and informed consent for procedures within the practice including photographic records.
I understand and consent to my photographs being used at Skin Lab by WPRS for medical research and education purposes and that in such use I will not be identified by name or nor will any features be portrayed that shall make my identity recognisable.
Signature
Date
MM slash DD slash YYYY

All patients will incur a fee which is payable in full at the time of consultation. Medicare rebates will be processed at the time of payment.

Comprehensive Skin Consultation: $150.00	Medicare rebate: $80.10
Extended Review Consultation: $125.00	Medicare rebate: $80.10
Brief Review Consultation: $90.00	Medicare rebate: $41.40
Minor Dermatological Procedures: $90.00	(Patient out of pocket full amount)
Major Dermatological Procedures: $135.00-$195.00	(Patient out of pocket full amount)

I have been informed of the potential costs involved in attending Skin Lab by WPRS and understand that payment of my account is my responsibility. I accept that if I default on my account, my details will be passed on to a debt collection agent, with all fees associated with such collection payable by me.
Signature
Date
MM slash DD slash YYYY
SKIN LAB BY WPRS MAILING LIST

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