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Acne New Referral Letter
Step 1 of 2
50%
First we need to ask you some questions.
I confirm I have a GP and will enter their details below.
*
Yes
No
I confirm that I have been diagnosed with acne by my doctor, or my skin looks like this:
*
Yes
No
I have used the following treatments for my acne:
Creams or gels
Oral antibiotics
Oral contraceptive pill
Roaccutane
Specialists Details
Specialist Name
*
Specialist Address
*
Specialist Telephone Number
*
Specialist Fax Number
GP's Details
GP's Name
*
GP's Address
*
GP's Telephone Number
*
GP's Fax Number
Special Notes
To complete your specialist referral letter , we need to obtain your medical history
Please select any conditions from the following list that apply to you now, or have applied to you in the past (leave blank if none apply)
Hypertension ( high blood pressure)
Heart disease
Stroke
Asthma
Thyroid disorder
Type 1 Diabetes
Type 2 Diabetes
Anxiety/depression
Epilepsy
Liver disease
Migraine (diagnosed by a doctor)
Cancer
Blood clots
Arthritis
Smoker
Other
We also need to know about any surgical history. Have you had any surgery in the past?
Yes
No
Please select any of the following that apply to you:
Appendicectomy
Heart Surgery
Bowel Surgery
Tonsillectomy
Gynaecological surgery
Weight loss surgery
Gallbladder surgery
Prostate surgery
Other
Have you had any allergies or bad reactions to any of the following medications?
Penicillins
Sulpha drugs
Antibiotics other than penicillin/sulpha drugs
Anti-inflammatories
Codeine
Morphine or morphine related medications
Other
I agree to provide an up-to-date list of all my medications to my specialist when I attend for my appointment
*
Yes
No
Do all the following apply to you? (please read carefully before confirming)
*
○ I am 18 years old or over, and currently in Australia.
○ This referral is for my own personal use only.
○ I understand that I am responsible for advising my specialist, and any other healthcare professional(s) I attend, of relevant information relating to my health and any changes in my health.
○ I understand that there may be a waiting list to see a specialist- if my condition gets worse in the interim I will seek medical attention.
○ I am aware there may be out of pocket costs for attending a specialist, which I will discuss with them.
○ I agree to the terms and conditions of use.
Yes
No
Thank you for completing this questionnaire- please click NEXT below to continue your booking
Please select a Video consultation or Phone Consultation
*
Phone Consultation
Video consultation
Please enter your Phone number
*
Confirm your phone number
*
Please complete payment and then choose your appointment time.
The following times are available to book a consultation.
Please complete the following steps:
Purchase the consultation from the shopping cart
Select and confirm your telehealth consultation time
Click on the sms or email link 15 minutes prior to the start of your consultation time
The doctor will call you on the video link during your chosen time slot
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