Initial Appointment Request

Patient Name & Surname *

Contact Ph: *

Email Address: *

Reason for appointment: *

Please attach your referral and any other relevant medical information

GP, Dermatologist or Specialist Referral

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Pathology or Radiology Reports

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Any pathology reports such as biopsy results or medical imaging such as xray/ultrasound reports

Other Medical Documents

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Any other relevant medical reports such as previous op reports, other doctors letters etc

Photographs

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Upload photos relevant to your treatment

WorkCover Approval Letter (if applicable)

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