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    Online Patient Registration Form

    Today's Date : 19/11/2017
    First Name : Surname :
    Your Address :
    Suburb : Postcode :
    Home Tel : Work Tel : Mobile :
    How would you prefer to be contacted during business hours (e.g. Mobile):
    Email Address:
    (This is our preferred method of contact for reminders/newsletters)
    Date of Birth :   / / Sex :   Occupation :

    How did you learn of Heber Davis?
    :
    Doctor Referral (Name and Address) :
    :
    Please identify your main concern/s.
    Have you had previous treatment for this concern? :
    When?

    By what method?

    With what outcome?

    Have you been on Roaccutane or other medication for your skin in the last 12 months? :
    Which medication?

    Are you using skin care products containing AHA's (fruit acids such as lactic acid or glycolic acid), Retin A or other vitamin A products? :
    If yes, please list

    Are you pregnant or breast feeding? :

    Do you have a history of poor healing or keloid scarring? :
    Please indicate if you have a prior history of:

    Have you ever had a cold sore? :

    Have you had any reactions to local anaesthetic? :
    If yes, please specify

    Please list any allergies

    Do you take any of the following? aspirin, hormones, oral contraceptive, cortisone, blood thinners, herbal preparations :
    If yes, list

    About you:
    /day
    /day Social Drinking
     
    It is important that we understand your skin type. When exposed to the sun for one hour with no protection, which category best describes your skin's reaction?
    When was the area to be treated last exposed to the sun or solarium?

    Do you use fake tan?

    Are you planning a holiday in the sun?

    OUR CANCELLATION POLICY:

    Short notice makes it hard for us to fill these appointment times. Please be aware that we require at least 24 hours notice, for any cancellation. A fee of $100 will be charged if this notice is not given. In special circumstances this can be waived by the practice manager, but credit card details will be required to secure the next scheduled appointment. Thank you for your understanding.

    Please insert your name to agree to our policy.

     

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