Western Dermatology

New Patients

If you are a new patient or returning after a period of 12 months or more, please complete the New Patient form on the right and click Submit.

Referrals

A referral letter from a General Practitioner or Specialist is required to claim the Medicare rebate. Please email office@westernderm.au or fax 08 9389 6748 a copy of your valid referral prior to your appointment.

Urgent Appointments

If you require an urgent appointment please send through a copy of your valid referral either by fax on 08 9389 6748 or email office@westernderm.au

Cancellations

We will contact via text or phone call one week prior to your appointment. Please contact us on 08 9389 6736, providing at least 48 hours notice, to cancel your appointment. Unconfirmed appointments are forfieted to urgent cases and may incur a subsequent booking fee.

Parking

Paid parking is available either at the front of or behind Hollywood Medical Centre. On-street parking is available around Hollywood Medical Centre, with time restrictions of one or two hours.

Public Transport

Bus stops are located on Monash Avenue, Hampden Road, Stirling Highway and Hospital Avenue. Bus routes 24, 25, 97, 103 and 950 service these bus stops, which are less than one kilometre from Hollywood Medical Centre.

Train stations close to Hollywood Medical Centre include Shenton Park, Dalglish and Karrakatta.

Title
Name (as on Medicare Card)
Preferred Name
Gender
Birth Date
Birth Country
Marital Status
Occupation
Residential Address Line 1
Residential Address Line 2
Suburb
State
Postcode
Postal Address
- Same as Residential Address
- Different from Residential Address (please provide details below)
Postal Address Line 1
Postal Address Line 2
Suburb
State
Postcode
Contact Number
Email
Emergency Contact Name
Emergency Contact No.
Referring Doctor
Are you allergic to any Medications, Creams or Surgical Dressings?
Any previous Skin Cancer,Skin Disease or Melanoma
Family history of Skin Disease?
Current Medication
Are you on any blood thinners?
- Yes
- No
Current Creams and Lotions
Medicare Card No (including reference)
Parent Full Name (if patient is under 18)
Parent Date of Birth (if patient is under 18)
Private Health Insurer name and number (if applicable)
DVA Card No (if applicable)
DVA Card Colour (if applicable)
DVA Card Expiry (if applicable)
Pension/Health Care Card No (if applicable)
Pension/Health Care Card Type (if applicable)
Pension/Health Care Card Expiry (if applicable)
I agree to pay a fee of $50 for each unattended appointment unless I provide at least 24 hours notice of cancellation. I acknowledge that I will be responsible for all costs incurred in recovering any overdue accounts.
PATIENT PRIVACY INFORMATION We aim to provide high quality dermatological care. In order to perform this task we will ask you for some personal details. These details will be collected and recorded, both by staff and myself. The Australian Privacy Act requires medical practitioners to obtain consent from patients to collect, use and disclose their details. Basic information is used to identify your record and may be used for Medicare and accounting purposes, to plan and organise any test, investigations and medical referrals. The remainder of your medical record is strictly confidential. A report will be sent to your referring doctor unless you specifically request otherwise. If further referral is required, information may be included in the referral letter. Other than meeting medical and legal requirements, information is not released to anyone else without your approval. If any of the details in your record change, please let my staff know so they can make any corrections. I consent to the collection, use and disclosure of my personal information as indicated above.
Signature and Date Required
Submit

Thank you for submitting your New Patient details to Western Dermatology.

If you have any queries please contact us on (08) 9389 6736.

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Western Dermatology

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