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Home of skin cancer education for medical practitioners

Request an appointment on line

Fill in this form to request an appointment

A referral is required.

Payment in full is required on the day.

Pensioners and Veterans Affairs patients are usually bulk billed, - but there are exceptions.

Read our full pricing policy here.

Cancelation requires at least 24 hours notice.

Complete the following details and submit. We will email a response.

 

Submit this form to organise an appointment

Fill in your details and click "submit"

First name*
Last name*
Street Address*
Town / Suburb*
Postcode
State / Territory / NZ
Country
Date Of Birth - Day/Month/Year*
Email Address*
Referring doctor
Where on your body is the lesion of greatest concern?
If you have private insurance, which fund?
Has you lesion of greatest concern been biopsied?



Do you have preferred day of week for appointment?





If it has been biopsied, is the lesion?
If you have not had a biopsy, does your doctor suspect?
Home phone
Mobile phone
Confirm email address
Other details about your skin lesion?
Comment?
Submit
*Required