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60 Patmos Road, London, SW9 6AF
Tel. 020 3049 6500
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Mole Check Online Consultation

Please fill out the form below, and one of our doctors will contact you regarding the consultation:

Patient Information

Name: *
Date Of Birth: *
NHS Number (if known):
Address:
Postcode:
Contact Number: *
E-Mail Address: *

Consultation Information

1. Do you have a combination of fair skin, blue eyes and fair hair?

Yes

No

2. Approximately how many moles do you have?

  • Did you know?
  • Skin cancer is one of the most common types of cancer in the UK, and the number of people who develop skin cancer is increasing.
  • According to Cancer Research UK, over 13,000 people are diagnosed with melanoma (a type of skin cancer) every year in the UK.
  • Remember, some melanomas don't start in a mole so any new pigmented blemish should be examined.

I have more than 20

I have between 10 and 20

I have just a few moles

I have no moles

3. Have you ever been severely sunburnt, with blistering and pain afterwards?

Yes

No, not severely

No

4. Has a close family member ever had a cancerous mole?

Yes

No

Don't know

5. Do you have a mole with any of the following characteristics?

Larger than 4mm diameter or has got bigger

Changed colour, developed different colours or got darker

Changed shape or become irregular around the border

Has risen above the skin surface

No

6. Does your mole bleed, itch, scale or ulcer?

Yes, I have two or more of these signs

Yes, I have one of these signs

No, I don't have any of these signs

7. Do you have any large, irregular (atypical) moles?

Yes, I have 6 or more large irregular moles

Yes, I have 1 to 5 moles

No, I have no large irregular moles

8. How often do you use sunbeds?

  • Sunbeds and the law
  • In April 2011, it became illegal for under 18s to use sunbeds.
  • The Sunbeds Regulation Act 2010 aims to protect under 18s in search of a year-round tan from putting their health at risk.
  • The Act means that under 18s cannot use tanning salons and sunbeds at premises including beauty salons, leisure centres, gyms & hotels.

Often, at least once a week

Sometimes - once or twice a month

Every 2-3 months

Rarely, less than once every six months

Never, but I have in the past

Never

9. Upload up to 3 images of your mole(s) (optional)

  • Please do not upload any images containing nudity
  • Images must be no larger than 2mb in size

Image 1:


Image 2:


Image 3: