Medical History:

Do you have, or have you ever had, any of the following? Tick Yes or No. If unsure, leave blank.

Family History Of:

I hereby declare that I have carefully considered the statements I have made above and that to the best of my belief they are complete and correct. I further declare that I have not withheld any relevant information or made any misleading statements. I understand that if I have made any false or misleading statement in connection with this application, or if I do not consent to release the supporting medical information, the Authority may refuse to grant me medical clearance or may withdraw any medical clearance granted, without prejudice to any other legal action applicable.

Consent to release of medical information: I hereby give my consent that all relevant medical information may be released and submitted to the medical assessor of the Licensing Authority.

Note: Medical Confidentiality will be respected all times.