Patient Consent Form

First Name

Last name

Date of Birth

Medicare Number/ IRN

Providing your medicare number to our private doctors will not result in your prescription being recorded directly to Medicare. Your Medicare information is used for e-scripting only and your information will only be held by the prescribing doctor and the dispensing pharmacy.

Email

Phone Number

Multi-line address

Country/Region

Address

City

Zip / Postal code

Gender

Weight (kgs)

Height. (cm)

Emergency Contact (Name & Number)

Do you have any Allergies?

No

Yes

Are you currently taking any prescription medications

No

Yes

Any Additional Information, if needed.

Do you accept our terms of use?https://www.rejuvenage.com.au/termsofuse

Signature

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