This health practice collects information from you for the primary purpose of providing quality health care.
Your consent is required to collect information about you.
You are required to provide your personal details and a full history so that you can be properly assessed, treated, and be proactive in your health care needs.
Please understand that not disclosing relevant health issues and/or medications or other ingestible therapeutics will reduce the efficacy of your assessment and treatment protocol (s).
This means the information you provide will be used in the following ways:
· Administration purposes in running this health practice;
· Billing purposes;
Disclosure to others involved in your health care, including treating doctors and specialists outside this health practice. This is done in cases where a second opinion is sought in order to guide you to the relevant health service(s) that you might need in order to address your ailment(s).
This information will stay private and confidential at all times.
Please note: Immunisation details are asked for accurate medical history. You do not have to disclose this information on this form should you wish to do so. However, it is important for your health assessment and outcomes and for the purpose of note taking.
This practice does not discriminate according to your immunization status. Please discuss any issues you might have in regard to this information directly with your practitioner.
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 client information.
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 treatment given to me.
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 have read and understood this information.