Free Skin Consultation Rockingham

Step 1

Your details

This form is detailed so we can understand your skin, health history and goals before we organise your consultation.

First name *

Last name *

Birth day *

Birth month *

Birth year *

How did you hear about us? *

Email address *

Name of person who referred you

Phone number *

Street address *

City *

State *

Post code *

Would you like to receive promotions and specials? *

Email meText meNo thanks

Would you like to receive appointment confirmation and reminders? *

Email meText meNo thanks

Emergency contact name and mobile number *

Step 2

Health history

Your answers help us make safe, suitable recommendations. If something needs a doctor's clearance, we'll let you know before treatment.

Have you had a skin cancer check in the past year? *

Have you ever had any spots or lesions removed, including cells for biopsy? *

Have you had any surgery within the past 12 months? *

Do you have any metal implants, dental implants, amalgum fillings, screws or plates? *

Do you have a hearing aid? *

Any known allergies? *

Are you currently or planning to undergo any dental procedures? *

Have you ever had a reaction to anesthetic medication? *

Do you suffer from claustrophobia or anxiety? *

Have you had cancer or treatments for cancer in the past? *

YESNO

If yes, when, what and where?

Are you currently undergoing any medical treatments or assessments? *

Please list any medical conditions you currently have or have had in the past that could affect the normal functioning of your body.

Do you take any medication or supplements? *

YESNO

Please list your supplements, medications and dosages *

Step 3

Skin concerns

Step 4

Consent

Please read and accept each consent item before submitting your consultation request.

Photography Consent

I consent to photographs and/or videos being taken of my skin and treatment areas for clinical assessment, treatment planning, progress monitoring, and medical record purposes.

I understand that these images will be stored securely as part of my confidential patient record and will not be used for marketing, advertising, social media, educational, or promotional purposes without my separate written consent.

I have read and agree to Photography Consent *

Fees and Payment Policy

As a privately billed clinic, payment is required in full on the day services are provided unless otherwise agreed in writing.

Refunds are not provided for consultations, services rendered, treatment packages already commenced, or change of mind purchases. If you have concerns, please discuss them with the clinic as soon as possible.

I have read and agree to Fee and Payment Consent *

Informed Consent

I understand that information, advice and recommendations provided during my consultation are for general skin health and aesthetic purposes only and are not intended to diagnose, treat, cure or prevent any medical condition.

I confirm that the information I have provided about my health, medications, allergies and medical history is accurate and complete to the best of my knowledge.

I have read and agree to Informed Consent *

Signature — type your full name *

Date day *

Date month *

Date year *