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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:
Email Address
Please tick to verify that you are not a robot
Latest Blog
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Can I Breastfeed After Breast Reduction?
Posted on 5 September 2021
Can I breastfeed after breast reduction? Theoretically speaking, one should still be able to breastfeed after ...
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Posted in:
Breast
breast reduction
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What is Capsular Contracture?
Posted on 6 June 2021
1. What is Capsular Contracture? Capsular Contracture is a tightening of the scar tissue that forms arou...
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Posted in:
plastic surgery
Breast implants
Breast
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What is an SCC (Squamous Cell Carcinoma)?
Posted on 7 March 2021
Squamous cell carcinoma (SCC), is the second most common form of skin cancer. This cancer is an uncontroll...
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Posted in:
plastic surgery
Skin Cancers
Skin
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Breast Implants, Breast Cancer and Screening
Posted by Dr Lily Vrtik on 10 January 2021
There are controversial and contradictory information about breast implants, breast cancer and breast canc...
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Posted in:
plastic surgery
Breast implants
Breast
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 "What is Capsular Contracture?")
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