Doctor Referral Form
Please enter patient details and select from treatment options below:
LLC Cosmetic Laser Clinics (Brisbane CBD and Lawnton)
Ph: 07 30921378 E: admin@llccosmetic.com
LLC Cosmetic Laser Clinics are a team of doctors, medical physicists and nurses who carefully consider cosmetic needs of each individual patient using the latest technology and a results focused approach.
Referring Dr Name and Practice Details
Contact Email for Referring Doctor
Patient's Full Name
Patient's Email Address
Patient's Mobile Number
Treatment(s) patient is being referred for
Free Radiotherapy Tattoo Removal (For ex-radiotherapy patients)
Scar Removal (Surgical/Stretchmark/Burn scar)
Acne Scar Removal
Melasma Removal
Poikiloderma of Civatte
PCOS Laser Hair Removal
Tattoo Removal
Rosacea Treatment
Freckle Removal
Pigmentation Removal (Age spot/Sunspot)
Skin Tag Removal
Cherry Angioma Removal
Seborrheic keratosis
Active Acne Treatment
Please choose the clinic patient would like to attend:
Brisbane CBD
Lawnton
Not sure
Any additional information
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