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MEDICAL HISTORY
This information is intended to assist Ivanhoe Cricket Club in case of any medical emergency.
All information is held in confidence.
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Player's Name
*
Your answer
Address
*
Your answer
Date of Birth
*
MM
/
DD
/
YYYY
Phone number
*
Your answer
Email
*
Your answer
Emergency Contact Name
*
Your answer
Emergency Contact Relationship to you
*
Your answer
Emergency Contact Phone Number
*
Your answer
Family Doctor Name
*
Your answer
Family Doctor Address / Practice Name
*
Your answer
Family Doctor Phone Number
*
Your answer
Medicare Card Number
*
Your answer
Health Care Card Number
Your answer
Health Insurance Fund
Your answer
Health Insurance Policy Number
Your answer
Ambulance Cover Policy Number
Your answer
Do you presently take any prescribed or non-prescribed tablets or medicines?
*
Yes
No
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