Consent Form

All clients are required to complete the consent form below 48 hours prior to an appointment.

Given names *

Surname *

Preferred names

Email *

Date of Birth *

Address (Unit Number and Street) *

Address (Suburb and Postcode) *

Phone *

Date of Injury

Medicare Number *

Reference Number *

Expiry Date *

Insurer (ie. EML)

Claim Number

Claim Manager

Allergies

Do you drink alcohol? *

NeverYes

Do you smoke? *

NeverYesQuit

Medications

Medication Name

Dosage

Patient Authority

Your authority for the release and collection of medical information

I authorise and consent to any health professional, legal representative, rehabilitation provider, case manager, or Specialist Plus provider disclosing, releasing, or discussing records containing my personal medical information with one another. I understand this information is required for determining and managing my compensation claim, as well as assisting with my treatment.

I further authorise and consent that a photocopy of this authority will be sufficient proof of my consent to discuss or provide the requested medical information.

I do not consent to my personal information being disclosed to the following:

Enter Your Full Name As A Signature *

Date Signed *