Please complete the consent form 48 hours prior to your appointment

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 *