Personal Details
Emergency contact / Next of kin
Allergies
Current Medications
(Including over the counter medication)
Personal and Family Medical History
Personal
Family
Relationship
High blood pressure
Yes No
Yes No
Asthma
Yes No
Yes No
Blood clots or blocked arteries
Yes No
Yes No
Heart disease
Yes No
Yes No
Mental health illness
Yes No
Yes No
Diabetes
Yes No
Yes No
Other (surgery/cancer etc)
Yes No
Yes No
Smoking status
Please advise us if there is any way we can assist you in your health goals
Please read and tick each box below to provide your consent
Our practice uses a reminder system to help you maintain your health. The practice
sends reminders by post, email, telephone or SMS for procedures such as vaccinations, Pap tests and other health reviews.
I consent to being contacted with reminders to help me maintain my health
Yes No
Our practice also sends information to the Australian Childhood Immunisation Register and Pap Smear Register. These registers also send reminders, which can be helpful if you move.
I consent to being contacted with reminders to help me maintain my health
Yes No
Mount Medical Clinic collects medical information for the purpose of medical treatment and may consult with third parties in the interest of your care.
I consent to my medical information being collected and used as required for my health
Yes No
Mount Medical Clinic expects payment for services which incur fees on the day they are provided. Any expenses or costs incurred by Mount Medical Clinic in recovering outstanding monies including debt collection fees will be paid by the parties above.
I understand that Mount Medical Clinic requires payment on the day of treatment and consent to do so
Yes No