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New Medical Centre Registration
Personal Details
Applicant First Name
*
*
Applicant Last Name
*
*
Applicant Email
*
*
*
Applicant Mobile
*
*
Next of Kin Details
Next of Kin Full Name
*
Next of Kin Relationship
*
Next of Kin Mobile Number
*
Next of Kin Email
*
Emergency Contact Details
Emergency Contact Full Name
*
*
Emergency Contact Details (Email & Phone)
*
*
Consent
Consent To Be Contacted
*
Consent To Disclosure
*
Patient Guardian Consent
*
Medical Details
Smoker
*
Yes
No
Unknown
Non-Drinker
Current Medications
*
Medication Allergies
*
Past Alcohol Intake
Nil
Occasionally
Moderate
Heavy
Days Drinking Per Week
*
*
Standard Drinks Per Day
*
*
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