Skin sensitivity form – Awanui Labs

Skin sensitivity tests

Skin allergy testing is only available when requested by your Doctor. To request an appointment for skin allergy testing please complete the below information and we will contact you. We aim to make contact within two working days.

This field is for validation purposes and should be left unchanged.

Name(Required)

First Last

Date of birth(Required)

Contact person (if difference from above)

Contact phone number(Required)

Contact email address(Required)

Name of Doctor requesting the allergy testing(Required)

Do you know what allergens the Doctor has requested?(Required)

If we need to test for any foods, has the patient had a reaction in the last 4 weeks where they have experienced swelling, difficulty breathing or required urgent medical treatment?

Yes

If yes, please state symptoms and what date they cleared:

Where would you prefer to have the test performed?(Required)

Wellington Hospital (Friday) / Hutt Hospital / (Wednesday) / Masterton Hospital (Tuesday afternoon only) – Please note: These are the usual days for clinics at each location, this may be subject to change.

We can assign an appointment time and email this to you with further information about the test, or we can phone you to discuss a time. Which would you prefer?(Required)

Email me (morning appointment) – not available for Masterton

Email me (afternoon appointment)

Phone me to discuss

Additional comments

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