Dermatologists Referral Form

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7 Ashley Lane
ABN 23 001 578 105
WESTMEAD NSW 2145
Phone: (02) 8833 3000
Fax: (02) 8833 3090
Dermatologists’ Referral Form
Urgent Review
Next Available
Patient’s Name:
_________________________________________________________________________________________________
____ /____ /____
Phone:
Male
Female
D.O.B:
_____________________________________
Patient’s Address:
_______________________________________________________________________________________________
Primary Diagnosis/History/Notes:
________________________________________________________________________________
Specialised Clinics:
Please select area of specialty required and/or your specialist of choice:
General Dermatology &
Hyperhidrosis:
Cosmetic Dermatology:
Excisions
including Rosacea, Acne scarring, Facial Peels
Dr Liang Joo Leow
Dr Tanya Gilmour
A/Prof Pablo Fernández Peñas
Dr Michael Lee
Patch Testing
Dr Liang Joo Leow
Dr Adrian See
Dr Joe Konya
Dr Tai Phan
Dr Howard Studniberg
Dr Adrian See
Dr Brian Wallace
Phototherapy
Laser & Light Therapies:
Dr Supriya Venugopal
Narrowband UVB treatment. Dermatologist
ALA/Photodynamic Therapy,
referral required. Full Body as well as hand and
Ablative, BBL/IPL Hair Removal & Photo
foot available.
rejuvenation, Pigment, Nd-Yag and Vascular.
Hair, Nail & Genital
Professorial Review, Research &
Dr Michael Lee
Dermatology:
Clinical Trials
Dr Liang Joo Leow
Dr Liang Joo Leow
Dr Shawn Richards
A/Prof Pablo Fernández Peñas
Hair Reduction Clinic:
Dr Adrian See
Dr Howard Studniberg
Nurse led clinic for treatment of excessive
hair. Dermatologist referral required. Skin
Types 1-3 treated.
Surgical Consultants:
Please select area of specialty required and/or your specialist of choice:
Cosmetic Surgery:
Mohs Consultations
Mohs Surgeons
Oculoplastic
& Surgery:
Surgeons:
(continued)
Rhinophyma, Port Wine Stains and
Birthmarks, Acne, Surgery and Chicken
Dr Michelle Hunt
Consult in private rooms
Dr Liang Joo Leow
Pox scar revision, Photo-damage
and conduct surgery at
Dr Sam Kalouche
reversal, Full face Chemical Peels.
Dr Shawn Richards
the Foundation:
Dr Michael Lee
Dr Shawn Richards
Dr Adrian See
Dr Tony Maloof
Dr Simon Lee
(Laser treatment under General
Dr Weng Sehu
Dr Liang Joo Leow
Anaesthetic also available)
Mohs Surgeons:
Dr Simon Taylor
Dr Liang Joo Leow
Dr Saleem Loghdey
Consult in private rooms
Dr Angelo Tsirbas
and conduct surgery at
(Laser treatment under General
A/Prof Rob Paver
the Foundation:
Dr Krishna Tumuluri
Anaesthetic also available)
Dr Andrew Satchell
Dr Phil Artemi
Dr Adrian See
Dr Tanya Gilmour
Dr Duncan Stanford
Dr Rhonda Harvey
Dr Howard Studniberg
Referring Doctor’s Details:
Patient Action Required:
Doctor’s Name:
_____________________________________________________
To book an appointment, phone:
(02) 8833 3000.
Provider Number:
___________________________________________________
Please bring this referral form along
with you, to your appointment at:
Phone:
_____________________________________________________________
7 Ashley Lane, Westmead NSW 2145
Address:
___________________________________________________________
Doctor’s Signature:
__________________________
Date of Referral: ___ / ___ /___
A division of Skin & Cancer Foundation Australia
PATRON: Her Excellency Professor The Honourable Dame Marie Bashir AD CVO, Governor of New South Wales

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