Follow the steps to accurately complete the form.

1. Click the ‘Get Form’ button to access the NZ MoleMap Patient Consent Form. This action will allow you to open and review the form for completion.
2. Begin by filling in your contact details. Include your title, first name, surname, date of birth, occupation, and all relevant phone numbers (home, work, and mobile). Be sure to include your email address and physical address details, including suburb and postcode.
3. Provide information about your nominated doctor. This includes their name, address, suburb, postcode, and phone number. This step ensures the doctor receives your assessment report.
4. Select the type of consultation you are requesting today by checking the appropriate box. Options include full body MoleMap assessment, follow-up, skin check, short-term follow-up, or spot check. Specify the duration for spot checks, if applicable.
5. Carefully read each statement in the mandatory items section. These statements outline your consent for the MoleMap assessment and should be marked to acknowledge your understanding and agreement. Your initials or signature may be required next to each consent item.
6. For the use of data consent, actively agree or disagree to allow your information and images to be used for research purposes by striking a line through if you do not consent.
7. If applicable, complete the spot check specific lesion consent section by marking your understanding of the limitations associated with the diagnosis provided.
8. Once you have completed all sections of the form, review your information for accuracy. Save changes to ensure no data is lost. You can then download, print, or share the completed form as needed.

Complete your MoleMap consent form online today for a thorough skin assessment.