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A non-judgemental and compassionate approach

Client Consent Form

I am required by the Australian Government Privacy Act to present the following material to you.

I ask that you sign this form to indicate that you have read and understood the contents of this document.

I will be collecting information from you for the primary purpose of providing quality health care. I require you to provide me with your personal details such as name, address, contact telephone numbers and other personal information, which is relevant to the service being provided. I require your consent to collect this personal information about yourself.

Additionally I may use the information in the following way:

  • Administrative purposes in running my practice;
  • Billing purposes, including compliance with health insurance fund requirements;
  • Disclosure to others involved in your health care, including treating doctors and specialists outside this practice;
  • Referral if necessary to other health care providers;
  • Disclosure to workers' compensation insurers or the Insurance Commission of WA in the case of compensation related treatment and assessment.

CLIENT DECLARATION

Please include your full name
You must consent to all declarations (tick all boxes)
You must consent to all declarations (tick all boxes)
You must consent to all declarations (tick all boxes)
Please consent to all declarations (tick all boxes)
Please consent to all declarations (tick all boxes).
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