Form: Employee Emergency Contact & Medical Details
Medical Information
Full Name
*
Mr.
Mrs.
Prefix
First Name
Middle Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Birth
*
-
Day
-
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
Medicare or Private Healthcare Card. (E.g. Australian Medicare Card, Medibank Private Membership Card).
Medical Conditions
Please list any allergies or medical conditions here. Please provide full details.
E.g. Allergic to seafood - I will break out in hives around the mouth and require an EpiPen.
Upload Documentation relevant to Medical Condition (E.g. an Asthma Management Plan).
Do you have any dietary requirements. Please provide full details.
E.g. I have a lactose free diet but I am not allergic to milk (diet is by choice).
Immunisation records (please upload your most up to date immunisations record)
Browse Files
Drag and drop files here
Choose a file
Your vaccination record must consist of: measles/mumps/rubella, Tentanus, Dipthria & Acellular Pertussis (whooping cough), chicken pox, influenza, Hepatitus A & covid vaccination.
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Emergency Contact: Primary Contact (AUSTRALIAN CONTACT)
(Must be a person residing in Australia)
Full Name
*
First Name
Last Name
Relationship
*
E.g. Mother, friend
Phone Number
*
-
Area Code
Phone Number
Emergency Contact: Secondary Contact
(Secondary Contact / Overseas Contact)
Full Name
*
First Name
Last Name
Relationship
*
E.g. Friend, sister
Phone Number
*
-
Country Code
-
Area Code
Phone Number
Submit
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