Emergency Contact

Date *

Member name *

Emergency contact name *

Relationship *

Phone (Mobile preferred) *

Is there a Medical Practitioner that we should contact?

Medical Practitioner Phone

Medical conditions and allergies

Do you have Diabetes? (Yes/No)

Have you ever had any form of Epilsey? (Yes/No)

Do you have any Medical, Physical or Mental disabilities that may adversely affect your ability to use power tools or machinery? (Yes/No)

Do you have a Pacemaker or other condition that prohibits the use of a Defibrillator? (Yes/No)

If you responded "Yes" to any of the above, please provide details

Do you carry medication? (Yes/No)

If "Yes" please provide detailsThe information that you have provided will remain confidential and only be used by HWMS to assist you in the case of a medical emergency.

Have a query?

Contact Form

Located

33A Sefton Rd Thornleigh NSW 2120