Teledermatology: New Patient Registration Form
This is the Teledermatology patient registration form, which is offered by the Centre for Medical and Surgical Dermatology.

Please complete all of the questions to successfully submit the Registration Form.
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Please type 8 digit identification pin number: (This will be used to identify you - please write this number down to not forget it.) *
The main reason for today's visit: *
Is your current skin condition: (Select all that apply.) *
Required
Have you seen a dermatologist for this condition before? *
How long have you had this issue? *
Have you tried any medications for this issue? *
Please list any medications you have tried: (Type "none" if this does not apply to you.) *
Personal Past Medical History/ Current Diseases: (Select all that apply.) *
Required
Please list any other medical conditions that apply to you: (Type "none" if this does not apply to you.) *
Have you reacted to Local Anesthetics in the past? *
Family History: (Select all that apply.) *
Required
Do you have allergies to Medications/Latex(s)? *
Please specify any allergies: (Type "none" if this does not apply to you.) *
Alcohol drinks per week: (Type "none" if this does not apply to you.) *
Cigarettes per day: (Type "none" if this does not apply to you.) *
Years smoking: (Type "none" if this does not apply to you.) *
Please list current Medications/Supplements: (Separate Medications/Supplements by using commas. Type "none" if this does not apply to you.) *
Please specify height: *
Please specify weight: *
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