Confidential Updated Medical Record

Client Information

First Name

Surname

Date of Birth

Email

Street Address

Suburb/Town

Postcode

Home Phone

Mobile Phone

Work Phone

Medical Information

Name of Medical Doctor

Telephone

Medical Practice Address

Postcode

Emergency Contact

Name of Emergency Contact

Phone Number of Emergency Contact

Additional Questions

NONE OF THE ABOVE APPLY

Please list any current medications

Please list any allergies

Consent

I have completed the above questionnaire to the best of my knowledge and understand that failure to make a full disclosure may place me at undue medical risk. I agree to be responsible for the payment of all services rendered on behalf or my dependents. In the event where my overdue account is referred to a collection agency and/or law firm, I will be liable for all costs which would be incurred as if the debt is collected in full, including legal demand cost.

Print Name

Date

Signed

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Parent/Guardian Signature

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(if appropriate)