Patient Information

Complete this form for an Online consultation of your skin issue.

Depending on consultation request volumes, please allow up to 3-5 business days to respond to your request. For faster service, please call or send email to info@moleclinic.ca

The Mole Clinic respects your privacy. Your answers are encrypted for your safety and security. This form is completely optional and you do not need to complete it to get service at our clinic.

If you do not feel comfortable providing the information, please call us at 877-336-6537 to speak to a staff member.

Are you concerned about skin cancer? *

Yes

No

I'm not sure what it is

IMPORTANT: If you are concerned about skin cancer you will need to get a doctor referral faxed to us at 519-720-0282. You can get this from your own family doctor or from a Walk-In Clinic doctor.

First Name *

Last Name *

Your email: *

Please re-enter your email: *

Best contact phone number to reach you *

Best time of day to reach you?

Can we leave a voice message if you are not available? *

Yes

No

Who is your family doctor? *

Have you contacted us or visited our clinic before? *

Yes

No

Tell us about your concern

Type of skin lesion *

RECOMMENDED: Please upload clear photos of your skin lesion.

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Did you review this problem with your family doctor? *

Yes

No

Please describe the reason for this visit *

Mole	Skin tag
Wart	Cyst
Lipoma	Botox Cosmetic
Botox for Migraines	Botox for excessive sweating (hyperhidrosis)
Dermal Fillers (Juvederm, Teosyal, etc.)	Injection Sclerotherapy for Varicose Veins
Platelet-Rich Plasma rejuvenation	Vivier Skin Care Products
Whole body mole assessment - skin cancer screening	Other Other