Parents Questionaire
  • Child details

  • Date Format: DD slash MM slash YYYY
  • Parents details

  • Date Format: DD slash MM slash YYYY
  • Emergency Contact

  • Medicare / Healthcare details

  • Privacy Information (Please read carefully)

    I understand that the Kids Health Space complies with the Privacy Act (2001) and as part of their Privacy Policy, they are committed to protecting the privacy of individuals and their personal information. The purpose of collecting my personal information is to provide quality medical and health related services and associated account keeping. I understand I have the right to request access to my information except where access would be denied, and that the Kids Health Space makes every effort to manage my information in accordance with the National Privacy Principles and keep my records up to date and accurate. I understand I may withdraw my consent (except when legal obligations must be met).

    My signature below indicates that I have read the above and consent to:
    1. Collection, use, storage and disposal of my personal information,
    2. Release of relevant personal information or images to other health professionals (e.g.: Specialists etc)
    3. Photographs of wounds
    4. Receive correspondence via email and SMS is un-encrypted