Date of Birth:
Gender: —Please choose an option—MaleFemale
Select Venue and Date: —Please choose an option—Sandown - July 7thSale - July 9thMurtoa - July 12thMildura - July 23rdGeelong - August 13thBendigo - August 20thBenalla - August 30th
Select Service:
General Health CheckLaser Skin AssessmentGeneral Health Check AND Laser Skin Assessment
Select Time: —Please choose an option—9:30am9:45am10:00am10:15am10:30am10:45am11:00am11:15am11:30am11:45am12:00pm12:15pm12:30pm12:45pm1:00pm1:15pm1:30pm
You have elected to attend a Vital Health Checks General Health Assessment and or Laser Skin Assessment. The General Health Assessment involves a suite of tests to monitor and assess your Health and Well-Being. The Laser Skin Assessment is a full body laser examination or an examination of suspect spots or moles (you determine the extent of the examination).
All assessments and screenings will be conducted by an experienced and qualified medical practitioner. Once the medical practitioner on the day identifies any potential problems, you will be referred to your general practitioner for further follow up.
Vital Health Checks and your Employer accepts no liability of any kind to you or anyone else for any personal injury, damages or loss whatsoever (including direct, indirect, incidental, special or consequential damages) arising out of any reliance upon or use of the information or products provided during the consultation. You acknowledge that your participation in the consultation and the use of the information and products provided during the consultation is at your sole discretion and risk. Vital Health Checks expressly disclaims all express and implied warranties to the maximum extent permitted by law. Should you have any queries regarding the diagnostic results obtained, please refer immediately to your usual medical practitioner. You warrant that the information provided by you on this form is true, complete and correct.
I have read and understand the above and hereby agree
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