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Health Status: Tick whichever of the following you have had or do have

 Heart condition Rheumatic fever Strokes Dizziness Visual Blood pressure Diabetes Cancer Memory impairment Convulsion Breathing difficulties Asthma Tuberculosis Numbness Other

 I understand that clinic does not hold accounts and I agree that all services rendered to me are charged directly to me and that I am personally responsible for payment.Where covered by Transport Accident Commission or Workers Compensation, I agree to pay for my treatment and collect a refund from the relevant agency myself.