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Skin Lesion Referral Form
Name:
First Name:
Last Name:
Date of Birth:
Patient Contact Number:
This referral is valid for:
12 months
Indefinite
Preferred Location:
Everton Park
Sunnybank
Urgency:
Urgent (within 10 days)
Semi-Urgent (within 4 weeks)
Prompt Attention (within 8 weeks)
Non urgent
Appointment:
Patient will call for an appointment
Please call patient with an appointment
An appointment has already been arranged
Please call next of kin with an appointment
Next of Kin Contact Number:
Clinical Referral:
Specific Lesions.... And /Or
Multiple skin lesions to be assessed and treated as required
Site & Size:
Has it been Biopsied:
Yes
No
Attachments:
Additional notes, Past Medical History, Medication List, Relevant Pathology/ Imaging Results
Referrer's Name:
First Name:
Last Name:
Email for confirmation of receipt:
Referrer Contact Number:
Provider number:
Date of Referral:
Spam Verification:
Please tick to verify that you are not a robot
Latest Blog
Read More
What is a BCC (Basal Cell Carcinoma)?
Posted on 1 April 2019
BCCs are abnormal, uncontrolled growths or lesions that arise in the skin's basal cells, which line...
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Posted in:
plastic surgery
Skin Cancers
Skin
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Breast Implant Related Anaplastic Large Cell Lymphoma
Posted by Dr Lily Vrtik on 1 February 2019
What is BIA-ALCL? This is a rare form of lymphoma that develops adjacent to breast implants. It is difficult t...
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Posted in:
plastic surgery
Breast implants
Breast
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What is Breast Hypertrophy?
Posted by Dr Lily Vrtik on 9 January 2019
Breast hypertrophy is by definition disproportionally large breasts with excessive breast tissue. This may occur as e...
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Posted in:
Breast
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Recent Changes in Medicare on Breast Implant Replacement
Posted on 3 December 2018
From 1st November 2018, there have been some changes made to the MBS with regards to breast implant sur...
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Posted in:
plastic surgery
Breast implants
Breast
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