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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:
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Latest Blog
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What is Capsular Contracture?
Posted on 30 November 2019
1. What is Capsular Contracture? Capsular Contracture is a tightening of the scar tissue that forms...
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Posted in:
plastic surgery
Breast implants
Breast
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What is an SCC (Squamous Cell Carcinoma)?
Posted on 1 October 2019
Squamous cell carcinoma (SCC), is the second most common form of skin cancer. This cancer is an uncontr...
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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 1 August 2019
There are controversial and contradictory information about breast implants, breast cancer and breast c...
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Posted in:
plastic surgery
Breast implants
Breast
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TGA Suspension of Textured Implants
Posted by Dr Lily Vrtik on 11 July 2019
Today (11th July), TGA (Therapeutic Goods Administration) has proposed regulatory actions to susped or cancel text...
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Posted in:
Breast implants
Breast
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 "What is Capsular Contracture?")
 "What is an SCC (Squamous Cell Carcinoma)?")
 "Breast Implants, Breast Cancer and Screening")