Medical Service Request - OccMedic Medical Service Request Form

Full Name

Date of Birth

Have you had a skin check before?

Yes

If yes, when?

Do you (or someone else) regularly check your skin?

Yes

If yes, how often?

Were you born in Australia?

Yes

If not, what age were you when you came to Australia?

Other?

Do you work outdoors?

Yes

To your knowledge have you been exposed to industrial chemicals

Yes

If yes, please give details:

Do you regularly use sun protection

Yes

If yes, what?

Hat

Cover Up

Sunscreen

Rate your sun exposure between the ages of 12-25 years

Low

Medium

High

Extreme

Rate your sun exposure between the last 12 months

Low

Medium

High

Extreme

Have you had blistering sunburn before age 12, or more than 5 times in your life

Yes

How does your skin react to sun exposure?

Burns

Goes red

Tans

Other

Other?

Have you used a solarium more than 6 times? (Solarium is any tanning unit that uses ultraviolet UV radiation to tan the skin)

Yes

If yes, how many times?

Have you undergone radiation treatment or UV therapy?

Yes

Are you on blood thinners?

Yes

If yes, please list:

Are you on any medication or do you have any illnesses that reduce your immune system function?

Yes

If yes, give details

Do you have a pacemaker?

Yes

Do you have a family history of skin cancer

Yes

If yes, please give details:

Have you ever had any form of skin cancer?

Yes

If yes, what type

BCC

SCC

Melanoma

Other (give details)

Are you concerned about any particular mole or spot

Yes

Have you noticed any new or changing moles?

Yes

Do any of your moles get itchy or bleed?

Yes

if yes to the previous three questions, please make note of any concerning spot/s

• I understand the Screening Skin Examination process is labour intensive and there may be a nurse or other assistant present throughout the screening process.

• I accept the Screening Skin Examination and clinical photography are aids to the diagnosis of skin lesions and may not have 100% clinical accuracy.

• I am aware that if I do not disclose skin lesions or areas of concern that are concealed by my underwear that I will accept full responsibility for any clinical outcome that not disclosing or allowing examination of these areas may lead to.

• I am aware that I am able to bring a chaperone to my Screening Skin Examination.

• I consent to the clinicians and staff performing a full skin examination and the use of clinical photography, as described above, during this examination.

Please provide the security code above.

OccMedic Medical Service Request Form

Welcome to our secure medical service request portal. please use this form to submit details for your workers and request specific medical services. Your data privacy is our utmost priority.

Contact Person Full Name

Contact Person Email

Contact Person Phone Number

Worker's Date of Birth

If 'Other' service requested, please specify:

Brief Description of Service Requirements/Reason for Request if required

Preferred Date for Service

Preferred Time for Service

Level of Urgency for this request

Routine (within 1 business days)

Urgent (organised within the next few hours)

Emergency (immediate attention required, will follow up with a call)

Any Additional Notes or specific instructions?

Please provide the security code above.