Mole Mapping Self Referral

Please complete and submit the below form.

Mole mapping self referral form

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Consent Information

I hereby authorize the mole mapping and skin check procedure to be performed by a trained staff at the Gippsland Specialist Clinic. I have been informed of the purpose, nature, and potential risks and benefits of the mole mapping and skin check procedure in this website, and I understand that the procedure involves the detailed examination and mapping of my moles and other skin lesions using specialized imaging technology.
I understand that during the mole mapping and skin check procedure, body images may be captured and stored for the purpose of monitoring any changes in my skin over time, as well as for reference and comparison in future mole mapping and skin check appointments. I understand that these images may include full-body photographs and close-up images of specific moles and lesions.
I understand that the body images will be stored securely and confidentially in accordance with applicable privacy laws and regulations, and that they will only be accessed and used by authorized healthcare providers for the purpose of my care and treatment.
I would also have the opportunity to ask questions about the mole mapping and skin check procedure, including the capture and storage of body images, before and during the procedures and I understand that I am free to withdraw my consent at any time before or during the procedure.
I acknowledge that I have received a copy of this consent form and that all my questions and concerns have been addressed to my satisfaction.

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I understand and agree to the above statement in relation to the collection, use, privacy and disclosure of patient information.

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Mole Mapping Payment

Once you have submitted the form, please click the ‘Pay Now’ button to complete the payment for your Mole Mapping.

$279

Mole Mapping Self Referral

Please complete and submit the below form.

Mole Mapping Payment

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