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Patch Testing Referral Form

Date of referral

Patient Name *

First

Last

Patient email address *

Date of birth *

Address *

Address Line 1

City

State / Province / Region

Postal Code

Phone number *

Layout

Referring Dr: *

Provider No: *

Correspondence to: *

Referring Dr Email *

Layout

Interpreter/ Auslan required *

Clinic *

Contact dermatology
Occupational dermatology

Reason for Patch Testing referral *

Medical History (including relevant medications): *

Click or drag files to this area to upload. You can upload up to 3 files.

Attachments – referral/history/photos *

Click or drag files to this area to upload. You can upload up to 3 files.

Patch testing appointments require patients to pre-pay for their appointments; $750 for pensioners/healthcare card holders and $950 for all other patients.

This payment is required 6 weeks prior to the appointment. A member of the administration team will call to take payment. This payment must be made within 48 hours of this call. Otherwise, the appointments will be cancelled.

If patients cancel within 10 business days of their appointments, they will forfeit $450 of the pre-payment amount, unless a medical certificate is supplied. The remaining amount will be refunded.

Deposit will be deducted from final payment on conclusion of Patch Testing.

Checkboxes *

Patient notified of deposit requirements

Patch Testing Referral Form

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