Child Registration Form (Under 18)
Welcome to the Crown Medical Centre. To help us provide you with the best possible service, we would be very grateful if you would take the time to answer the following questions. Thank you.
Please help us trace your previous medical records by providing us the following information:
Family history:
Medical history:
Please state any on-going illnesses or any significant past illnesses, operations or accident and the years they happened or started.
Please list medications that you are taking at the present time and the dosage.
Please state any allergies that you have and the date which they started.
Privacy Protection
Information submitted through secure forms is used only for the purposes of processing your request. We may
be in touch with you in relation to the information submitted.
All Information submitted through secure forms is secured with a private key and is accessed over a secure
connection by nominated staff. We have a strict confidentiality policy.
This information is not shared with any third party organisations.
This information is retained for up to 28 days.
Learn more about our Privacy Policy and
Terms of Use.
Should you have any concerns about sending your personal details using the web,
please use one of the alternative methods offered by our organisation.