Referral

Dormir Group Skin Specialists

Referral Form

Rapid Access Skin Cancer Surgery

Patient First Name

Patient Last Name

Patient Date of Birth

Patient Phone

Patient Address

Patient Email

Practitioner First Name

Practitioner Last Name

PRACTITIONER PROVIDER NUMBER

Practitioner Address

Practitioner Phone

Practitioner Email

Location of Skin Cancer

Biopsy

Yes No

Pathologist

Patient History/Current Medications

Allergies

Surgeon Being Referred To

Upload at least one photo with the lesion clearly marked.

(07) 3544 6553

admin@brisbanedac.com.au

skin@dormirgroup.com.au

education@dormirgroup.com.au

Dormir Group Surgical Centre
Suites 201 – 203, Level 2, 
621 Gympie Road, Chermside 
QLD, Australia 4032