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A dermatologist carrying out a skin treatment in a modern clinic
For referring practitioners

Practitioner skin referral form

Refer a patient to the West Med skin cancer prevention service at The Sanctuary, Somerset West. Tell us what you are seeing and how soon you want it seen, and we report back to you.

Before you start

What we need from you

  • Your details and HPCSA number, and how you would like the report back, by email or by post.
  • The patient's contact details, so we can book them in directly rather than through your rooms.
  • What you are referring for: baseline or follow-up mapping, a second opinion on one lesion, field treatment, the nurse-led cream programme, or PDT.
  • The sites you are concerned about, marked on the outline, with how long each has been there and what has changed.
  • How urgent it is, and whether we report back before doing anything or may manage it and tell you.

Clinical lead Dr Scott, HPCSA MP0941745. Questions about a referral, or something you want to discuss before you send it? Call 021 490 4380 and ask for the skin service, or WhatsApp 068 923 6287.

Referring clinician

Patient

Reason for referral

Tick all that apply.

Relevant history

Lesions of concern

Front
Back

Click the outline to drop a numbered pin. The front view faces you, so the figure’s left is the patient’s right. Every site is labelled from the patient’s point of view, and you can correct the wording.

No sites marked yet. Click the outline, or add one below if you would rather type it.

    Have a dermoscopic or clinical photograph? Email it to referrals@west-med.co.za with the patient’s name and the site number, and it will be filed with this referral. Please do not attach images to any other address.

    Urgency, and what happens if we find something

    Urgency
    If we find a suspicious lesion

    Patient consent

    The patient agrees to this referral, and to information and images being shared between the referring practice and West Med for the purpose of their care.

    Information on this form is used only for this patient’s care. It reaches the practice as a single email and is not stored on this website. Images are kept in the patient record and shared only with consent, with the people named above.