Patient Information Form - The Caps Clinic


patient information form
Title: ____________ First names: _____________________ Surname:___________________________
Address: ___________________________________________________________ Postcode: _________ Date of
birth: ______/______/________ Occupation: _________________________________________ Contact
Numbers: (h) __________________ (w) ____________________ (m) ______________________ Email:
__________________________________ Marital Status: _________________________________ Next of Kin:
_____________________________ Next of Kin Phone: ______________________________ Parents Names (if
patient is under 18 years): _________________________________________________
How did you hear about 360UV? __________________________________________________________
Medicare Number: ___________________________________ Card Ref No _______ Exp: ___________
Private Health Fund: _______________________________ Membership Number: __________________
Pension Number: __________________________________ Expiry: ______________________________ DVA
Number: __________________________________ Card Colour: White / Gold
Family Doctor: _____________________________ Suburb: ____________________________________
Referring Doctor: ___________________________ Suburb: ____________________________________ Would
you like your family doctor to receive information relating to this consultation?
Yes 
No 
Current Medications / Blood Thinning Medication eg Asprin / Vitamins: _____________________________
Allergies: _______________________________________________________________________ Surgical /
Medical History: Diabetic / Heart Problems / Bleeding Problems: _________________________
_____________________________________________________________________________________ Do you
Yes / No
How many per day? ____________________________________________
Please complete if you are seeing the Doctor for a full body scan
In undertaking this examination I recognise that whilst identification and storage of my moles with the use
of a ‘scanning system’ is the best opportunity available for the early discovery and monitoring of skin
lesions or a possible melanoma, it is not 100% guarantee of detection.
I understand that Skin Lesions/Melanomas can arise in any part of the body, so I hereby consent to
Please tick one of the following:
 A full examination of my body including breasts and genitals
 A full examination of my body excluding genitals
 A full examination of my body excluding breasts and genitals
Privacy Statement: It is the policy of 360UV our patient’s personal health information will only be used or disclosed in the provision of a
patient’s care. The clinic has established a privacy policy in compliance with the National Privacy Act of 2001. Copies of this policy are
available on request.


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