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MEDICAL HISTORY AND GENERAL HEALTH FORM - Doctors
Nameyour full name
DOB
Allergiesfull name
Medications
0 /
Current Medical problems
0 /
Past Medical History
0 /
Local Doctor Name
Local Doctor Address and phone number
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Have you had previous Pathology / Radiology relating to this current condition?
0 /
Where tests were performed
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 We are a collaborative team of General Practitioners and Allied Health Services. Your health and Wellbeing is important to us. We would like to inform findings with your referring Practitioner. Your information will not be given to 3rd parties unless we have your written consent.

Do you give permission for your information to be shared with other Medical Practitioners and Allied Health professionals at Smart Health?
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