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Patient Consent Form
First Name
(Required)
Last name
(Required)
Date of Birth
(Required)
Email
(Required)
Phone Number
(Required)
Multi-line address
Country/Region
(Required)
Address
(Required)
City
(Required)
Zip / Postal code
(Required)
Gender
Weight (kgs)
(Required)
Height. (cm)
(Required)
Emergency Contact (Name & Number)
(Required)
Medicare Number
(Required)
Goals
Muscle and Strength Gain
Weight Loss
Muscle and Injury Repair
Anti Ageing
Sexual Health & Libido
Memory/ Cognitive Enhancement
Immunity
Other
Do you have any Allergies?
No
Yes
Are you currently taking any prescription medications
No
Yes
Current Medical Conditions
None
Cancer, past or present
Epilepsy
Hypertension
Diabetes: type 1, type 2
Thyroid Disorder
Chest Pains, Palpatations (irregular or fast heart beat), shortness of breath with exercise?
Any Respiratory illnesses acute and chronic
Any Heart conditions, past or present
Anxiety, depression, insomnia: other psychiatric issues
Other
Any Additional Information, if needed.
Do you accept our terms of use?
https://www.rejuvenage.com.au/termsofuse
(Required)
Signature
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