Welcome to the Radien Dermatology Patient Information Form.

Please complete the form below for signing when you come in for your appointment.

  • Please note: If a skin biopsy or an excision is performed, the tissue sample we be sent to pathology. The pathologist will bill you for this. Medicare rebates apply.

    ** Payment for consultation is required on the day. If this is inconvenient, please see our receptionist to book another appointment.** Thank you for your assistance.

    I AGREE TO PAY ON THE DAY FOR THE CONSULTATION. I UNDERSTAND THAT EXTRA CHARGES APPLY FOR ANY PROCEDURES PERFORMED.

    Signed ........................................................ Date ..........................

  • The Privacy Act prevents us from obtaining information regarding your medical history, previous medical records, test results, letters and other documents from health practitioners without your prior written consent

    It also prevents us from releasing any information regarding your medical history, previous medical records, test results, letters and other documents to other medical practitioners without your prior written consent

    If we do not have all your medical information, treatment and followup may be very difficult

    Obtaining and/or releasing such information may often be required in order for the Doctor to make an informed decision regarding your treatment and may also be required during the process of booking you in for tests or procedures.

    By signing this form, you give Radien Dermatology the right to store, obtain and/or release information regarding your medical history, previous medical records, test results, letters and other documents to/from other medical practitioners or hospitals.

    Name ........................................................ Date of Birth ..........................

    Signature ........................................................ Date ..........................

  • This field is for validation purposes and should be left unchanged.
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