PATIENT CONSENT FORM
The Well Men Program is
committed to providing you with the highest levels of customer service. This
includes protecting your privacy.
New
sections of the Commonwealth Privacy Act 1988 require we obtain your written
consent for the collection, use, storage and disposal of your personal
information.
Our
purpose for collecting your personal information is solely to provide quality
medical and health related services and associated account keeping. Please
note that without your consent the doctor cannot provide you with quality health
care.
Please read the following and tick each box as you go along then sign at the
end.
Consent:
I
UNDERSTAND THAT THE WELL MEN PROGRAM COMPLIES WITH THE PRIVACY ACT (1988) AND
AS PART OF THEIR PRIVACY POLICY THEY ARE COMMITTED TO PROTECTING THE PRIVACY OF
INDIVIDUALS AND THEIR PERSONAL INFORMATION. 
I
UNDERSTAND THAT I HAVE THE RIGHT TO REQUEST ACCESS TO MY INFORMATION (EXCEPT
WHERE ACCESS WOULD REASONABLY BE DENIED) AND THAT THE WELL MEN PROGRAM MAKES
EVERY EFFORT TO MANAGE MY INFORMATION IN ACCORDANCE WITH THE NATIONAL PRIVACY
PRINCIPLES AND TO KEEP MY RECORDS ACCURATE AND UP TO DATE. I UNDERSTAND THAT I
MAY WITHDRAW MY CONSENT FOR THE WELL MEN PROGRAM TO USE MY PERSONAL INFORMATION
EXCEPT WHERE LEGAL OBLIGATIONS MUST BE MET.
I THERE FORE CONSENT TO THE WELL MEN
PROGRAM: Please tick each box
·
COLLECTING,
USING, STORING AND DISPOSING OF MY PERSONAL INFORMATION IN ACCORDANCE WITH THE
PRINCIPLES SHOWN ABOVE.
Without this your Doctor cannot write notes about your health, or keep a file
about your previous history. We would not be able to identify you if you attend
more than once and no continuity of care would be possible. Disposing means
confidential destruction after legal required time.
·
RELEASING
RELEVANT PERSONAL INFORMATION TO OTHER HEALTH PROFESSIONALS TO ALLOW QUALITY
MEDICAL CARE.
Without
this your doctor cannot provide the necessary information relating to your
health if you are referred to a specialist or pathologist or other health
professional.
·
INCLUDING
MY INFORMATION IN A RECALL REGISTER SO THAT I WILL BE ADVISED OF NEEDED FOLLOW
UP VISITS, MEDICAL UPDATES AND RELEVANT HEALTH INFORMATION.
You
may need to be recalled from time to time to monitor and check certain aspects
of your
health or to be alerted to information that may be critical to you health.
·
INCLUDING
MY PERSONAL MEDICAL INFORMATION ANONYMOUSLY IN STATISTICAL REVIEW AND ANALYSIS
OF SYMPTOMS AND TREATMENT
FOR THE PURPOSE OF ONGOING IMPROVEMENT IN HEALTH CARE.
All
Well Men Program patients now benefit from the collective expertise and
experience developed and shared within the group. Only through constant
evaluation and review of results achieved are we able to provide the leading,
quality health care that we are committed to.
·
I
NOTE THAT IF I WISH THE WELL MEN PROGRAM TO RELEASE RELEVANT PERSONAL
INFORMATION TO MY EMPLOYER OR PROSPECTIVE EMPLOYER, THEIR AUTHORISED
REPRESENTATIVE AND THEIR INSURER IN THE CASE OF A WORK RELATED INJURY OR ANY
OTHER PARTY NOT PREVIOUSLY IDENTIFIED I MUST PROVIDE MY EXPRESS REQUEST
IN WRITING FOR THIS TO BE DONE.
Patient
Name
Date of Birth
Patient
Signature
.
Date
.