Medical form

Child's full name *
 
 
Girl
Boy
Date of birth *
Blood Group *
 

Particular comments

Allergies *
Ongoing treatment *
Precautions to be taken *
In case of fever we
Allow
Does not allow the nurse to give panadol for my child
 

In case of emergency

Your child will be transported by emergency services at the Belle Vue hospital.
Other hospital (Specify)
Pediatrician name
Phone
Date *
Security Code *
 

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