Patient Information

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

Your response will be reviewed by a licensed medical doctor and you will be called on the provided phone number(s) to discuss your concerns. OHIP will only be billed if the concern is medical. At the discretion of the medical doctor, he/she may elect to have you book an in-person consultation at our clinic.

Depending on consultation request volumes, please allow up to 5 business days to respond to your request.

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 instead or to book an in-person appointment.

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? NOTE: You may get a NO CALLER ID call. Please make sure your phone can accept calls like this.

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 *

OPTIONAL: Please upload clear photos of your skin lesion. 🛈

Did you review this problem with your family doctor? *

Yes

No

Are you concerned about skin cancer? *

Yes

No

I'm not sure what it is

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