New Patient Under 18 Form

Thank you for completing this form.

Please make sure you also complete the Medical History Form - https://molescopeskincancerclinic.snapforms.com.au/form/molescope-medical-history-form

Patient Details


Parent Guardian Details (for Medicare purposes)



Healthcare Details

Photography Consent

For almost all patients, clinical photography will be taken to assist in your care. These become part of your confidential medical records.  

These photos are stored in a secure server in compliance with the Australian Privacy Principles. They will be accessed by clinic staff and will not be sold or transferred to any other entity for purposes that have not been agreed to.

Patient General Consent

Molescope respects your rights to privacy and take our privacy obligations seriously. We comply with the Australian Privacy Principles, found under the Privacy Act 1988. Please contact reception on 9725-3003 if you would like a copy of our Privacy Policy.

We require your consent to collect personal information and health information about you. Please read this information carefully and sign where indicated below.

Molescope collects information from you for the primary purpose of providing you with healthcare services. We require you to provide us with your personal and health information so that we may provide our services to you. We will also use the information you provide to effectively communicate with third parties, including Medicare Australia and other practitioners involved in your healthcare (if required).

Molescope will access your information from My Health Record when required and can upload some clinical information to My Health Record.  We will only do this with your consent.

Molescope uses the DermEngine program to store and organise clinical photos taken during consultations.  DermEngine uses AI to detect changes between 2 photos (total body photography and dermoscopic images).  DermEngine does not ever have access to your name or any other personal information and DermEngine staff cannot access the photos or any information stored in the files.  If you wish to opt out of the AI features of DermEngine please talk to reception.  DermEngine complies with Australian privacy principles and the photos are stored on Australian servers.

Some Doctors may use AI scribes to write notes during consultations.  If these are used the Doctor will ask for verbal consent prior to use with every consultation.

I have read the information above and understand why my information is collected and how it is used. I acknowledge that I am not obliged to provide information requested of me, but that failure to do so might compromise the quality of care provided to me.

I understand that Fees are increased yearly on July 1st at the same time as the increase of Medicare rebates.  New Patients are quoted fees and those quotes will be honoured for appointments booked prior to fee increases, however, if the appointment is cancelled after July 1st and rebooked then the new fees will apply.

I understand that a cancellation policy applies for appointments booked at Molescope.  Appointments cancelled after 1pm on the Business Day prior to the appointment will result in a fee of $100 for Consultations and $200 for Procedures (with no Medicare Rebate available).  This also applies to patients who fail to attend their appointment or who arrive very late.  Please ring us if you are likely to be more than 10 minutes late for a consultation to discuss options.  Fees may be waived in the setting of an infectious illness but please contact us ASAP in that case.

The practice will send reminders for upcoming appointments by SMS.   Alternative contact methods will be used if there is no mobile number on file or if you prefer these not to be used.

The practice is starting a monthly email newsletter to share new developments in the clinic and in the Medical world relevant to our patients.  We will also send out periodic SMS messages (6/year maximum, but most likely twice a year) for any major clinic updates (such as a new Doctor starting).  Both require your consent (see below).

Thank you for completing this form.  Please sign below and then click on submit.

Please ring us on 9725-3003 if you have any questions.

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