Wynnum Medical Centre

T: (07) 3348 9000 F: (07) 3806 5451

7/1795 Wynnum Rd - Tingalpa QLD 4173
www.Wynnum-Medical-Centre.com.au

Full Skin Check Patient Consent

Name:_______________________________________ Date of Birth: ________________

We recommend a full body skin check every time you come for a skin check because some skin
cancers are found on areas of the body not commonly exposed to the sun. Dr Davood Karimian (Dr
Davood) offer a full body skin check which requires you undressing down to your underwear. If you
have any concerns regarding our protocol please discuss this with Dr Davood prior to the
consultation. A staff member can be made available to attend your consultation upon request.

Although you may be a regular patient of the Practice, we would appreciate your assistance in
answering all the questions below:

1. Have you used any makeups today? (This may affect the accuracy of examinations)
Yes No

2. Do you have any electronic device in your body e.g. Pacemakers, Nerve stimulators, ..?
Yes No

3. Have you got any allergies? (eg. Betadine, Friars Balsam, adhesives, medications etc)

_______________________________________________________________________

4. Do you take any medications? (eg. Warfarin, Aspirin etc)

_______________________________________________________________________

5. Where did you hear about Wynnum Melanoma Centre?

Friend/Relative Website/Internet A Doctor Flyer/Cards Other:

6. As Dr Davood will phone you with any results of any procedures (Biopsy or Excisions) do you
consent to a message being left on your preferred phone if you are unavailable when he calls?

Yes No Preferred Contact Number :

Patient signature: ____________________________________ Date:__________