Apply for Pre-Approved Finance with Q Card

Phone for further info 09 524 9002 Book Appointment Now

Note. all fields are compulsory and must be completed.
A copy of the data provided will be automatically sent to you for your records via the email address provided on this form.

Your Information


Medical history

Hospitalisation for illness or injury
An Allergic reaction to
Aspirin, ibuprophen, codeine
Penicillin
Erythromycin
Tetracycline
Sulphur
Local anaesthetic
Metals (nickel, gold, silver)
Latex
Other
Heart problems
Cardiac stent within last 6 months
Infective endocarditis
Repaired heart defect
Pacemaker
Rheumatic fever / scarlet fever
Other
Stroke (taking blood thinners)
Previous hip / knee replacement
High or low blood
High cholesterol
Anaemia or other blood
Respiratory
Liver problems (Cirrhosis, jaundice)
Kidney
Emphysema
Tuberculosis
Diabetes
Gastrointestinal problems
Osteoporosis / osteopenia
Thyroid, parathyroid disease
Hormone deficency
Arthritis
Sexual transmitted disease/ infection
Viral infections or cold sores
COVID-19 virus/ influenza
Hives, skin rashes hay fever
HIV / AIDS
Please circle relative type: Hepatitis (type: A, B,C)
Head or neck injuries
Epilepsy, convulsions (seizures)
Neurological problems (ADHD)
Emotional problems
Psychiatric treatment
Treatment for depression
Cancer treatment
MALE: prostrate disorder
Presently being treated for any other illness
Aware of any changes in your health (i.e. fever, new cough)
Taking medications for weight loss
Taking health or vitamin supplements
Often exhausted or fatigued
Experiencing frequent headaches
A smoker
Do you want to quit smoking
FEMALE: contraception
FEMALE: are you pregnant

Please advise us in the future of any change in your medical history or any of the medications you may be taking.

Verification

In order for us to verify that you are a real person, please check the I'm not a robot box below.

Site by 72DPI