Mon, Wed : - 8:30am - 5.30pm

Tus,Thu,Fri : 8:30am – 5:30pm

Sat : 9:00am – 12:30pm

Mount Medical Clinic,

1592 Burwood Hwy, Belgrave VIC 3160 Australia


    Personal Details




























    Emergency contact / Next of kin





    Allergies





    Current Medications

    (Including over the counter medication)

    Personal and Family Medical History

    Personal Family Relationship
    High blood pressure YesNo YesNo
    Asthma YesNo YesNo
    Blood clots or blocked arteries YesNo YesNo
    Heart disease YesNo YesNo
    Mental health illness YesNo YesNo
    Diabetes YesNo YesNo
    Other (surgery/cancer etc) YesNo YesNo





    Smoking status







    YesNo

    Please read and tick each box below to provide your consent

    Our practice uses a reminder system to help you maintain your health. The practice
    sends reminders by post, email, telephone or SMS for procedures such as vaccinations, Pap tests and other health reviews.
    I consent to being contacted with reminders to help me maintain my health YesNo
    Our practice also sends information to the Australian Childhood Immunisation Register and Pap Smear Register. These registers also send reminders, which can be helpful if you move. I consent to being contacted with reminders to help me maintain my health YesNo
    Mount Medical Clinic collects medical information for the purpose of medical treatment and may consult with third parties in the interest of your care. I consent to my medical information being collected and used as required for my health YesNo
    Mount Medical Clinic expects payment for services which incur fees on the day they are provided. Any expenses or costs incurred by Mount Medical Clinic in recovering outstanding monies including debt collection fees will be paid by the parties above. I understand that Mount Medical Clinic requires payment on the day of treatment and consent to do so YesNo


    I have read the email policy and privacy policy of the clinic and I consent to receive Emails/SMS :