Medical Information Form

Your Name*

Student Name*

Relationship to Student*

Address*

Street Address Suburb Post Code

Email*

Telephone Mobile*

Telephone Home*

Telephone Work*

MEDICAL INFORMATION

Medical Centre

Doctors Name

Doctors Telephone

Private Medical Insurance Company

Policy Number

Medicare Policy Number

HEALTH INFORMATION

Does your child suffer from any allergy, health condition or diagnosis requiring medication.*

Yes
No

If your answer is yes please give full details below

Symptoms following exposure

General precautions to prevent an emergency

REQUIRED TREATMENT & MEDICATION

1. Does your child require immediate medication

( if so please provide medication to be left with staff in the case it is required to be administered)

2. Can your child self administer medication?

YES
NO

3. If your answer to question 2 is NO? Do you give the Principal or a staff member permission to administer medication you have provided

YES
NO

Please give details of required medication & treatment

Does your child/you have a medical plan in place? Created by a GP or treating clinician

YES
NO

Medical Plan UPLOAD -Please attach file

Max. file size: 500 MB.

I

authorize for a ambulance to be called in the case of an emergency, all medical and surgical treatment, X-ray, laboratory, anesthesia, and other medical and/or hospital procedures as may be performed or prescribed by the attending physician and/or paramedics for my child and waive my right to informed consent of treatment. This waiver applies only in the event that neither parent/guardian can be reached in the case of an emergency.

Child Photo

Accepted file types: jpg, jpeg, png, gif.

For life threatening allergies or health conditions where immediate treatment or medication is required to be administered a current photo of the child is required.

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MEDICAL INFORMATION

HEALTH INFORMATION

REQUIRED TREATMENT & MEDICATION

ACCOUNTS: IMPORTANT ANNOUNCEMENT

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