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Medical Information
Do you have Medicare?
Please select...
Yes
No
Medicare Number
Medicare Expiry Date
MM/YYYY
Ref No. on Card
Do you have a Private Health Fund
Please select...
Yes
No
Private Health Fund
Membership No. & Scale
Type of Care
Please select...
Permanent
Respite
None
Respite ACAT Code
N/A if you don't know
Permanent ACAT Code
N/A if you don't know
Have you had a Flu vaccination?
Please select...
Yes
No
Flu vaccination date
Have you had a COVID vaccination
Please select...
Yes, Both doses
Yes, 1st dose
No
COVID vaccination date (1st dose)
COVID vaccination date (2nd dose)
COVID vaccine type
Please select...
AstraZeneca
Pfizer
Moderna
Other (please specify)
Other vaccine type
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