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The following card data needs to be filled ONLY if applicable.
Please provide your contact info.
Is your Home address not your Postal Address?
In case of an emergency, who is best to be contacted?
If you are not registered for My Health Record would you like to do so by providing us with 100 points of identification?
Are you of Aboriginal?
Are you of Torres Strait Islander Origin?
Do you identify with any Cultural Background?
You selected YES. What is your ethnic background?
Do you require a translator or help with filling in this form?
Would you like to receive
SMS / Email Reminders / Newsletters/ updates from our practice?
How did you hear about our clinic?
WILLOWGLEN MEDICAL CENTRE - NEW PATIENT HEALTH SUMMARYPlease fill this part of the form to the best of your knowledge.
Are you currently taking medication?
You selected YES. Please provide details of your medication below.
Do you have known Allergies or Sensitivities?
You selected YES. Please provide details below.
Have you ever had or have now any of the following conditions? Place a check for YES, leave blank for NO.
High Blood Pressure?
Shortness of Breath?
Are you a smoker?
You Smoke?! Please provide details below.
Are you an ex-smoker?
Great! Please provide details below.
Do you drink alcohol?
Please provide details below.
Have you had a pap smear in the last 2 years?
Have you ever had a mammogram?
Do you have any message for the Clinic Office?
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