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Unit 24, 3 Silas St,
East Fremantle.
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New Patient Registration
Register your details here to save time when you arrive at the clinic.
About You
Name
*
First
Last
Email
*
Address
*
Street Address
Address Line 2
City
State
Post Code
Country
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo
Congo, Democratic Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czechia
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syria Arab Republic
Taiwan
Tajikistan
Tanzania, the United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
Türkiye
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Phone Number
*
Date of Birth
*
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Date
Month
Year
Occupation
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Medicare Number
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Reference Number
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1
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Expiry Date (Month)
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1
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2031
2032
Your Health
Are you currently taking any medication? (Including vitamins and natural supplements):
*
Yes
No
Which medication, vitamins or supplements are you currently taking?
*
Do you have any allergies?
*
Yes
No
Please list your allergies below:
*
Have you had any cosmetic procedures (eg anti-wrinkle injections, dermal filler, laser, surgical) before?
*
Yes
No
Please list any cosmetic proecdures you have undertaken:
*
Please tell us about your medical history:
Your Treatment Options
To help us give you the most appropriate advice and options, to ensure that you get the most from your consultation, please indicate below:
What are you most interested in discussing?
*
Full face rejuvenation
Treatment of one particular facial area - eg lips
“Positive Ageing” treatment plan
Skin care
Non-injectable skin rejuvenation options
A particular treatment we offer
Other
Please tell us which treatment you are interested in:
*
Please explain:
*
Which type of management plan would most suit your lifestyle (please tick all that apply):
Select All
In-clinic treatments
Home treatments
Home cosmeceutical skin care regime
12-month treatment plan
How much downtime can you accept with cosmetic treatments?
None
A few days
1-2 weeks (if planned in advance)
Please select any of following treatments/services that are of interest to you:
Non-invasive treatment of vaginal ageing or post-birth vaginal/urinary issues
Permanent underarm sweat treatment
Cosmetic mole removal
Privacy Policy
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I have read and agree to the
privacy policy
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Offers and Updates
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Please indicate how you heard about The Skin Clinic Fremantle:
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Email
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Book Online
Face
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Wrinkle Treatments
Volume & Augmentation
EmFace®
Rejuran® polynucleotides
Double Chin
Eyelid rejuvenation
PDO Threads
Bio-Remodelling
Bruxism (Teeth-grinding)
ArqueDerma® Artistic Restoration Lift®
Body
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Emsculpt® – Body Sculpting
ONDA® Body Contouring
Sweat Treatments
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MiraDry Sweat Treatment
Emcyte® Hair Regeneration
Skin & Laser
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Alma Hybrid™ laser
HydraFacial®
Rejuran® polynucleotides
IPL Skin & Vascular
Soprano® Laser Hair Reduction
Emcyte® Pure Rejuvenation
Fire & Ice® Hollywood Facial
Liquid Exfoliants
Healite® LED Light Therapy
Mesotherapy
Dermal Needling
Dermaplaning
WiQo®
AviClear® Acne Laser
Tixel ®
Concerns
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Teeth Grinding
Acne
Rosacea
Pigmentation
Sweating
Scarring
Menopause Management
Skin Bar
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