Teledermatology Patient Registration Form
Patient Information
Patient name
First Name
Last Name
Patient email
example@example.com
Patient phone number
Please enter a valid phone number.
Date of birth
-
Month
-
Day
Year
Date
General Practitioner Information
Name of your General Practitioner
First Name
Last Name
Address of the medical center
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone number
Please enter a valid phone number.
If you are seeking our services in relation to a long-term, pre-existing (chronic) skin condition, Teledermatologist will require supporting details from your GP to assist in your diagnosis. Please give us the authority to contact your GP. Do you agree with that?
Your Skin Condition
How sensitive is your skin?
Least sensitive
1
2
3
4
Most sensitive
5
1 is Least sensitive, 5 is Most sensitive
The symptoms you are experiencing
Hair loss
Rash
Skin lesion
Wart
Skin irritation
Insect /animal bite
Acne
Nail fungus
Wrinkles/aging
Burn
Hyperhydrosis
Other
How long have you been experiencing your current problem?
Days
Weeks
Months
Years
Describe the problem that you experience in detail
Which parts of the body are affected?
Face
Neck
Shoulders
Leg(s)
Buttocks
Scalp
Underarms
Abdomen
Waistline
Back
Chest
Arm(s)
Groin
Genitals
Ears
Hands
Slides/flanks
Feet
Other
Do you experience any of the following?
Itching
Tenderness
Heat
Blackheads
Pain
Warmth
Buttocks
Whiteheads
Other
Is the problem spreading, or changing?
It's bleeding
It's getting lighter
It's changing shape
It's getting darker
It's enlarging
It's moving/spreading
Other
Do you have any allergies to medication or food?
Describe your allergy type and the medications/foods you have an allergy
Medical History
Describe any surgery, treatment, illness, or cancer you had with the used medications during the treatment in detail
Is there any medication that you currently take?
Your medications and dosages
Do you have a preferred pharmacy?
Pharmacy name
Pharmacy address
Confirmation and Consent
Please upload a file that shows the front and back of your ID card
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Upload a file provided by your doctors on behalf of your previous treatments
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Please review and tick to indicate your consent to all of the following
I confirm that the procedure for conducting the teledermatology consultation has been fully explained to me.
I understand that my participation is completely voluntary and I have the right to refuse to participate and may withdraw my consent and terminate the consultation at any time.
I understand that health professionals are permitted to take notes during the consultation.
In case I do not have a preferred pharmacy, teledermatology consultation authorizes me to a pharmacy around my given address.
I authorize the taking and storage of images for medico-legal purposes, diagnosis & further treatment.
I understand that telemedicine including teledermatology can have limitations due to the lack of physical contact with the patient by the dermatologist. Although unlikely, this may result in the Dermatologist being unable to provide an accurate diagnosis.
I understand that I will be contacted to organize initial and follow-up appointments and that it is expected that I will be able to reply to messages from Teledermatologist within a reasonable time frame. If I am unable to reply, then my next of kin and/or my requesting GP may be contacted about my case.
I confirm that if Teledermatologist has made a reasonable attempt to contact me about a follow-up appointment and, I have not responded, then Teledermatologist reserves the right to close my case.
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