We require your consent to collect personal information about you. Please read this information carefully, and sign where indicated below.
This medical practice collects information from you for the primary purpose of providing quality health care. We require you to provide us with your personal details and a full medical history so that we may properly assess, diagnose, treat and be proactive in your health care needs. This means we will use the information you provide in the following ways:
I have read the information above and understand the reasons why my information must be collected. I am also aware that this practice has a privacy policy on handling patient information. This privacy policy can be found on our website or a hardcopy can be obtained upon request.
I understand that I am not obliged to provide any information requested of me, but that my failure to do so might compromise the quality of the health care and treatment given to me. I am aware of my right to access the information collected about me, except in some circumstances where access might legitimately be withheld. I understand I will be given an explanation in these circumstances.
I understand that if my information is to be used for any other purpose other than set out above, my further consent will be obtained.
I consent to the handling of my information by this practice for the purposes set out above, subject to any limitations on access or disclosure of which I will notify this practice. I have the right to lodge a complaint about handling of my personal information if I am dissatisfied, which will be dealt with in accordance with the complaint handling procedure.
