PERSONAL DETAILS

First Name
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Last Name
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Email address
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Mobile Number
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Date of birth
dd/mm/yyyy
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What's your gender?
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Area checked
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if above answer is Specific, describe:
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DERMATOLOGIC HISTORY

When did you last have a skin cancer check?
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Have you ever had a skin cancer or sun spot removed?
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If yes, please specify:
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Has anyone in your immediate family had skin cancer?
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If yes, please specify:
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Have you had 3 or more sunburnt episodes, blistering your skin, within your lifetime?
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Have you ever used a solarium?
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If yes, please specify:
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Do you have a lesion of concern?
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If yes, please specify:
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Where do you do most of your job?
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RELEASE OF INFORMATION AND PARTICIPATION CONSENT
Participant Release of Information Consent pursuant to Federal Privacy Act 1988 (AU) or Privacy Act 1993 (NZ)



  • I confirm that my participation in this Skin Cancer Check is voluntary.

  • I acknowledge that any personally identifiable health information obtained in conjunction with this health check will be protected and will only be used in accordance with this agreement and applicable laws pertaining to the use of personal health information.

  • I understand that any health information obtained, may be used to compile a deidentified aggregate report for my company/employer. My individually identifiable health information will not be shared with my employer.

  • I consent to the collection of data on my skin type, sun damage and sun damage type.

  • I understand that the data derived from the check is considered to be preliminary and for screening assessments only. The data collected does not constitute a diagnosis. The responsibility for initiating a follow-up examination to confirm the results of this screening and obtain professional assistance is mine alone and not that of my employer or any organisation associated with these skin cancer checks.



    • I hereby give Bodycare Health & Wellbeing Pty Ltd consent to release the de-identified results of my health questionnaire as part of an aggregate result to the relevant department of my employer.
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    Date
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    SKIN CHECK RESULTS

    Skin Type

    Skin Type (Fitzgerald)
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    Sun Damage

    Sun damage:
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    Sun damage type:
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    Follow Up

    Are you under the care of a doctor or specialist for your skin?
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    Is a follow up required?
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    Notes
    Note suspicious lesions found and where (inc. SCC, BCC, M)
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    Submit