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Your Skin History
Have you had a previous skin damage diagnosis?
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Your Previous Diagnosis
Please supply the following details
How many skin lesions or damage skin areas were treated ?
Only 1
2 - 10
10 - 30
Many
Specifically what prior skin damage was found, or
Actinic Keratose
Sunspots
Precancerous Mole
Dysplastic naevus
Precancerous Lesions
Benign Keratoses
Other
What skin cancer diagnosis was made?
Squamous Cell Cancimoma
Basal Cell Carcinoma
Melanoma In Situ
Superficial Melanoma
Lentigo Maligna
Melanoma
Other
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Your Previous Skin Treatment
Date of Treatment (approx)
On this occassion how many skin lesions were treated ?
Only 1
2 - 10
10 - 30
Many
Skin Condition Treated?
Actinic Keratose
Sunspots
Precancerous Mole
Dysplastic naevus
Precancerous Lesions
Benign Keratoses
Squamous Cell Cancimoma
Basal Cell Carcinoma
Melanoma In Situ
Superficial Melanoma
Lentigo Maligna
Melanoma
Other
How was this Treated?
Surgical Removal or Excision
Topical Cream
Topical Chemotherapy
Curettage
Liquid Nitrogen
Photo Dynamic Therapy
Skin Re surfacing
Radiotherapy
Mohs Surgery
Other
Was the treatment a success?
Yes
No
Have you had more skin cancer treatments?
Yes
No
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Your Previous Skin Treatment (2)
Date of Treatment (approx)
On this occassion how many skin lesions were treated ?
Only 1
2 - 10
10 - 30
Many
Skin Condition Treated?
Actinic Keratose
Sunspots
Precancerous Mole
Dysplastic naevus
Precancerous Lesions
Benign Keratoses
Squamous Cell Cancimoma
Basal Cell Carcinoma
Melanoma In Situ
Superficial Melanoma
Lentigo Maligna
Melanoma
Other
How was this Treated?
Surgical Removal or Excision
Topical Cream
Topical Chemotherapy
Curettage
Liquid Nitrogen
Photo Dynamic Therapy
Skin Re surfacing
Radiotherapy
Mohs Surgery
Other
Was the treatment a success?
Yes
No
Have you had more skin cancer treatments?
Yes
No
Back
Next
Your Previous Skin Treatment (3)
Date of Treatment (approx)
On this occassion how many skin lesions were treated ?
Only 1
2 - 10
10 - 30
Many
Skin Condition Treated?
Actinic Keratose
Sunspots
Precancerous Mole
Dysplastic naevus
Precancerous Lesions
Benign Keratoses
Squamous Cell Cancimoma
Basal Cell Carcinoma
Melanoma In Situ
Superficial Melanoma
Lentigo Maligna
Melanoma
Other
How was this Treated?
Surgical Removal or Excision
Topical Cream
Topical Chemotherapy
Curettage
Liquid Nitrogen
Photo Dynamic Therapy
Skin Re surfacing
Radiotherapy
Mohs Surgery
Other
Was the treatment a success?
Yes
No
Have you had more skin cancer treatments?
Yes
No
Back
Next
PLEASE SUBMIT YOUR FORM
Submit
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