Your Name * Your Date Of Birth * Sex * MaleFemale Your Medicare Number * Email * Phone Number * Allergies * Present Illness * Past Medical History * Current Medications * Do you have any of the below conditions ? Heart Disease YesNo Asthma YesNo COPD/ EMPHYSEMA YesNo Diabetes YesNo Chemotherapy YesNo Would you prefer tele health consult via :* TelephoneSkype
