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The Skin Cancer Doctor
Skin Cancer – Onsite Detection and Surgical Management
BOOK APPOINTMENT HERE!
admin@theskincancerdoctor.com.au
1300 SKIN DR (1300 754 637)
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HOME
SERVICES
EDUCATION
CLINICS
CONTACT
GP REFERRALS
CAREERS
FAQs
Corporate patient details form for employee skin cancer checks
Corporate patient details form for employee skin cancer checks
Please enable JavaScript in your browser to complete this form.
Name
*
First
Last
Sex
*
Female
Male
Date Of Birth
*
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MM
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YYYY
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Address
*
Suburb
*
Postcode
*
State
*
Qld
NSW
VIC
WA
NT
TAS
Home phone
Mobile phone
*
Email
*
Email to be used to communicate appointment details and results etc. If no email address, write NA. Emails will not be passed on to third parties.
Medicare Number
*
Please write all 10 numbers on front of your card with no spaces
Medicare Line number
*
Number associated with family member on card to left of name
Medicare Expiry Date
*
Pension Card Number (if applicable)
Pension Card Expiry Date
What is the name of the company that you work for in which this service is being provided?
*
Are you an indoor or outdoor worker?
*
Indoor
Outdoor
Both
Your age range
*
Under 30
31 - 40
41 - 50
Over 50
When was your last skin cancer check?
*
Under 12 months
Over 12 months
Never
Do you have any current concerns relating to your skin and possible skin cancer?
*
Yes
No
You will have the opportunity to chat with the doctor about these concerns at the time of your appointment.
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