Rash - {{first name}} {{surname}}

General Information

First Name

Surname

Date of Birth

Email Address

Home Phone

Mobile Phone

Home Address

Medicare Card Number - IRN *

How did you find out about us?

Emergency Contact Information

Emergency contact

Phone

Emergency contact’s relationship to you

Work Information

Current work status

EmployedRetiredNot workingLight Duty

Occupation

Rash Details

When did you first notice the rash?

Where is the rash located?

Describe the rash (size, shape and colour).

Is the rash itchy?

YesNoUncertain

Has the rash spread?

YesNoUncertain

Is there any discharge from the rash?

YesNoUncertain

Have you been exposed to any new products or irritants?

YesNoUncertain

Any associated symptoms?

Medical Background

Please list all your medical conditions (e.g. High Blood Pressure, Asthma, Diabetes etc.)

Please list your medications (including Name, Dose, Frequency).

Please list any allergies.

Allergy

Please list any surgeries.

Surgery

Do you smoke?

YesNoI used to smoke

Do you use recreational drugs?

NoI have previously usedI currently use

Upload images of the rash.

Browse

Upload images of the rash.

Browse

Upload images of the rash.

Browse

Consent

I confirm that the above information I have provided is true, complete and accurate. I agree to be contacted by a health professional via telehealth. *

Signature

Draw signature|Type signatureClear

Date