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Your ACSIA Medication (drug) Allergy Action Plan referral will be ready soon. Cost $49
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Name of person requiring action plan

Please enter confirmed allergens(s)

Are you currently prescribed antihistamine?

Emergency Contact(s) full name and mobile

We must include your face in the ACSIA action plan, like the example. Please provide your face picture.

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Are you prescribed a Adrenaline injector if so which one

If I require a translator, I will provide one or I will contact TIS.  By signing below I agree and accept. I have read, understood and agree with the terms and conditions and privacy policy  I, declare I am residing in Australia and do not need urgent medical attention. I fully indemnify MIDOC, it’s related entities, directors, partner doctors, nurse practitioners and registered nurses, fully releasing them from any and all liability, claims, actions, injury, damages, expenses, or losses that may arise from the information or services provided including any forms of perceived or actual negligence. I acknowledge the inherent risks of telehealth and grant my full informed consent for these services and for any medicare related forms or assignment. I agree I will receive my results via email and follow up with my GP. 

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