Consent Form

I understand

LIst

My participation is voluntary. I have the right to withdraw my consent and cease consultations at any stage. The procedure for conducting telehealth consultations. The health provider will take notes during the consultation. My referring doctor and/or healthcare team may be contacted in reference to my treatments.

My consent relates to

LIst

A period of care which may involve several consultations via telehealth. The notes taken as a requirement by the funding body for my appointments are done so privately and stored within a secure platform. The sharing of information in relation to my treatment is to be sent to the nominated email address, which is a secure and safe address that only I have access. Permission for additional specified health professionals to be contacted in reference to my treatments.

I declare that all information provided on this form is true and accurate at the time of signing and that my identity is that stated on this form. If client not in care

Client Name

Select Date

Sinature

If client has a carer

Carer Name

Select Date

Sinature

Client has no access to email so verbal consent of client was taken via phone by

Provider name

Provider type

Select Date

Consent Form

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