Skin Exam Update · Dr. Blinkhorn & Dr. Whiting Family Practice

First time having a skin examination with us?

Use the full new patient intake form instead →

Patient Identification

Full Name *

Date of Birth *

Health Card Number (CPN) *

Sex * Used to direct you to the appropriate patient information and consent form

Today’s Visit

Are you scheduled for a full skin examination today? *

Before your full skin examination

Please read the patient information sheet about your full skin examination, and then complete the consent form. You are welcome to do this before your appointment.

Read Patient Information Sheet → Complete Consent Form →

New or Changing Lesions

Since your last visit, have you noticed any new or changing spots, moles, or lesions?

Are there specific areas you would like Dr. Whiting to focus on today?

Changes Since Your Last Visit

Have there been any significant changes to your medical history, medications, or immune status since your last visit?

Anything else you would like Dr. Whiting to know before today’s visit?

Skin Exam Update Form