Consent Form

Welcome to Neta Care,

Thank you for choosing support with our Allied Health team.

This document includes Neta Cares Health Care consent form for you to sign so that we are able to share information with our clinicians and to consent to the costs mentioned below. This form will take approximatey 10mins to fill in.

Medicare, Rebated Private Health and Self-funded Allied Health Therapy services at Neta Care will have a gap fee. The gap amount will depend on your scheme/insurance cover regarding your service type.

Please click here to view our full price list.

Please fill in the below information:
Name*

TitleFirst NameLast Name
Date of Birth*

DayMonthYear
Home Phone Number

Area CodePhone Number
Mobile Number*
Format: 0400 000 000.
Email*
SMS Approved : With your consent, we will send appointment reminders via SMSI consent to receiving Neta Care newsletters and updates
Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
YesNo

Postal Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

YesNo

Fund Name
Member Number

Health Care Service Consent Form

Purpose of Collecting and Holding Information

Neta Care requires you to provide some personal information for the primary purpose of delivering a quality service to you. This allows us to assess, diagnose and provide therapy appropriately and effectively. By signing this form, you consent to:

1.Your personal and health information being stored on Neta Care’s secure systems and databases for recordkeeping purposes. This includes professional notes, audio recording and video recording which may be takenby Neta Care’s Health Professionals for therapeutic purposes.

2.Your personal and health information being used for billing either directly or through third party fundingbody (i.e Private Health Insurance, Medicare & DVA).

3.Your personal and health information being used within the practice for therapeutic discussion or passingyour case to another practitioner within the practice for your ongoing management.

4.Your personal and health information being accessed and/or disclosed to and from your doctor, other healthprofessionals or other stakeholders who are involved in your care to facilitate communication and the bestpossible care for you.

5.Your personal and health information being disclosed to an external organisation if subpoenaed by a courtwithin the legal jurisdiction of Australia.

6.Your personal and health information being disclosed to an external organisation if failure to disclose theinformation would place you or someone else at serious and imminent risk.

7.Your personal and health information being shared to other external agencies if you provide a writtenrequest to Neta Care (e.g. lawyer)

We do not disclose your personal information to overseas recipients.

Neta Care has an Information Security Procedure that is available on request. That procedure provides guidelines on the collection, use, disclosure, and security of your personal and medical information. The procedure also contains information on how you may request access to, and correction of, your personal information and how you may complain about a breach of your privacy and how we will deal with such a complaint.

To ensure the process of quality treatment provision, information about your assessment results and progress may be given to relevant other service providers, who are involved in your management. These may include but us not limited to your doctor, teachers, specialists, insurers, solicitors, or employers.

INFORMED CONSENT

Informed Consent can be implied (you voluntarily lift your arm when asked) or given verbally or in writing. This written consent form is to ensure you have a general understanding about your treatment and relationship with Neta Care. Informed consent is an ongoing process, and we will inform you about your progress and foreseeable risks before any therapy interventions. We will then confirm that you continue to give informed consent (verbally or implied) to the therapy and record your responses on your file. It is likely that physical contact will be necessary during the course of examination, assessment and treatment for many of our therapy services (i.e Physiotherapy). You may withdraw your consent at any time and any physical contact will cease immediately. Please inform your therapist if anything can be done to assist your comfort or if you have any concerns.

THERAPY RISK FACTORS

General potential risk factors may include but are not limited to:

⋅ Physical joint and/or muscle soreness.
⋅ Temporary skin irritations
⋅ Temporary soreness, bleeding or bruising.
⋅ Nausea or dizziness
⋅ Emotional discomfort

Your therapist will always attempt to minimise the risk factors associated with therapy intervention, however, if symptoms do not subside you are required to inform your therapist immediately and seek emergency medical attention if required.

FEES AND CANCELLATION POLICY

Please refer to the appropriate fee schedule for your allocated consultant as the fees and rebates vary between disciplines. The cost of your appointment is required to be paid at the conclusion of your appointment by credit/debit card. Cancellations and rescheduling of appointments less than 24 hours prior to your scheduled appointment will incur a cancellation fee. This fee is the full fee which would have been charged for the service. Cancellation fees are not able to be claimed under Medicare, Private Health, or any other Insurance Scheme. You will be liable to pay the full amount either over the telephone or at your next attendance.

I have read and understood the above consent form. I have been provided with the opportunity to request a copy of relevant procedures and been provided with opportunities to discuss this with my therapist or the Executive Health Officer at Neta Care. I agree to these conditions for all health care services provided by Neta Care, and I understand and agree to Neta Care’s fee policies and required payment agreement. I hereby agree that all the information above is correct, and I understand that I will not be able to make a claim against Neta Care or my Neta Care Health Professional for any illness, injury or change in medical status due the utilisation of Neta Care equipment or treatment/therapy provided.
I have read the above information and understand the reasons for the collection of my personal information and the ways in which the information may be used and disclosed and I agree to that use and disclosure. I understand that it is my choice as to what information I provide, and that withholding or falsifying information might act against the best interests of my assessment and therapy progress. I am aware that I can access my personal and treatment information on request and if necessary, correct information that I believe to be inaccurate. I understand that if, in exceptional circumstances, access is denied for legitimate purposes, that the reasons for this and possible remedies will be made available to me. I also understand that I have the right to request to revoke consent at any point in time. This may limit certain types of services from being provided (eg: Medicare Rebated Services).
Any supporting files, please upload to the box below

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Signature*
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