Burpengary East Medical Centre & Skin Cancer Clinic – Skin Form

Burpengary East Medical Centre & Skin Cancer Clinic - Skin

If registering a child, please provide the parent or guardian's phone number.
If registering a child, please provide the parent or guardian's email address.


Cultural Background

Medicare - Healthcare - Pension Card Details

Eg. 0123456789
Eg. 1
Eg. 02/20

Next of Kin

Emergency Contact

Medical History

Skin Check Details

Important Practice Information

The doctor will examine your skin with a dermatoscope to check for skin cancers, You may be requested to remove your clothes but you will not be required to remove any undergarments such as bra or underwear. It is your responsibility to highlight any lesions that may be covered by your clothes, Your privacy is our upmost concern and your health is our priority, if you prefer to have a chaperone during examination, kindly let us know and we will organise it. Any out of pocket expenses will be explained to you by the doctor before any procedures are undertaken. You may be asked to return for further check ups or treatment if appropriate.


BULK-BILLING IS NOT ROUTINE & you may receive an account for your visit which must be paid on the day of consultation. Payments can be made by eftpos or credit card. However ,patients on a Pension, Concession or Health Care Card may be Bulk Billed at Doctors discretion. We direct bill all Department of Veteran Affairs Gold Card holders. Certain medical examinations - such as medicals, legal reports & commercial drivers licences are not claimable from Medicare. Full Payment is required on the day for Workcover claims that do not currently have a claim number. You are then able to follow this up with your claim agent. If you require any further information regarding costs please ask reception staff.

Freedom of information

All patient files that include personal information, test results etc. are the property of this practice. However , should you choose to visit another Doctor at any time, copies of the appropriate files can be forwarded on receipt of your written request. Under no circumstance will this practice divulge personal information without your prior written consent.


I have read the information and I consent to have my Skincheck. I understand that skin lesions and moles can occur over time and I would return to the clinic if any such changes occurred and I would return for follow-up previous as recommended.
The patient must sign to confirm that they agree.