Luxe Medical Procedures
LUXEMEDICAL PROCEDURES
1300 16 26 97 • 235 Darby St, Cooks Hill 2300
www.luxemedicalprocedures.com.au

Client Intake • Confidential

Client Intake Form

Please complete each section as accurately as possible. This information helps our clinical team prepare for your visit and is kept confidential in accordance with the Privacy Act 1988.

Patient Information

Basic details we'll use to identify your chart.

Contact Details

Please enter a physical street address — PO boxes can't be accepted.

Emergency Contact

Medical History

Check any that apply to you.

Allergies

Current Medications

List everything you're currently taking, including all prescribed and over-the-counter medications, all supplements, and any drops, sprays, ointments or creams.

Lifestyle

Consent to Luxe Medical Procedures to gather and hold my personal information

I authorise Luxe Medical Procedures to gather my personal information for the purposes of providing me with medical treatment. I understand that this information will only be used by Luxe Medical Procedures for the purpose stated, and my information will not be shared with any third party unless expressly requested by me or required by law. Luxe Medical Procedures relies on the information I have provided here to ensure my safety, and I confirm that I have provided full and accurate information to the best of my knowledge.
Signature
Date
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Received

Thank you — your form has been submitted.

A member of our care team will review your information before your appointment. If anything changes before your visit, you can let the front desk know.