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.

GUIDELINES FOR TAKING A CLEAR PHOTO OF YOUR SKIN LESION:

1. Set Up the Background: Choose a place with a solid-color background to avoid distractions. If you don't have a solid-color background, you can hang a plain sheet or cloth.

2. Lighting: Ensure good lighting. Natural light is best, but if that's not possible, use a bright lamp. Avoid shadows by making sure the light is shining directly on the area.

3. Camera Position: Take photos from three different distances:
Medium view: About 2 feet (0.6 meters) away to focus on the specific area.
Close View: About 1.5 feet (0.5 meters) away to capture details of the mole.

4. Focus: Make sure the camera is in focus. If using a smartphone, tap the screen to focus on the mole.

5. Multiple angles: Take photos from different angles to give a comprehensive view.

6. Avoid Zooming: Instead of zooming in, move the camera closer to the mole to maintain image quality. Don't move too close or the image will become blurry.

7. Steady hands: Keep the camera steady to avoid blurry images. Using a tripod or asking someone to help can be beneficial.

8. Include a Ruler if possible: For size reference, place a ruler next to the mole in one of the photos.

9. Review photos: Check the photos to ensure they are clear and well-lit before sending them to your healthcare provider.

Following these steps will help your physician get a clear view of the mole for better assessment.

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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