Vita Health Care

1281 Nepean Hwy, Mount Eliza 3930

Ph: 5972 2444

Fax: 9787 2906

Email: reception@vitahealthcare.com.au

CONSENT TO SHARE INFORMATION

General Information

I am completing this form for: *

MyselfAnother person or Minor (under 16)

Patient first name *

Patient surname *

Preferred Name

Date of birth *

Parent/Guardian Information

Parent/Guardian First Name *

Parent/Guardian Surname *

Parent/Guardian Contact Number *

Relation to patient *

Please specify (other) *

Personal/health information to be shared

Please provide the details for all individuals/organisations for whom you are providing consent for the sharing of information by the above-listed Vita Health Care clinician/s. Please include the details of your referring GP/medical clinic. For individuals aged over 16, please include parents/caregivers/spouses as appropriate.

Contact Details of Third Party:

(Where/whom the information will be shared to)

Contact Name *Example: Dr John Smith, Ms Jane Doe, Professor Martin

Contact Type *

Please specify (other) *

Third Party NameExample: Sunflower High School, Strawberry Medical Clinic

Third Party AddressExample: 1293 Nepean Highway, Mount Eliza VIC 3930

Phone Number

Email/Fax

Add another contact

Contact Details of Third Party #2:

(Where/whom the information will be shared to)

Contact Name *Example: Dr John Smith, Ms Jane Doe, Professor Martin

Contact Type *

Other Type (please specify) *

Third Party NameExample: Sunflower High School, Strawberry Medical Clinic

Third Party AddressExample: 1293 Nepean Highway, Mount Eliza VIC 3930

Phone Number

Email/Fax

Add another contact

Contact Details of Third Party #3:

(Where/whom the information will be shared to)

Contact Name *Example: Dr John Smith, Ms Jane Doe, Professor Martin

Contact Type *

Please specify (other) *

Third Party Name *Example: Sunflower High School, Strawberry Medical Clinic

Third Party AddressExample: 1293 Nepean Highway, Mount Eliza VIC 3930

Phone Number

Email/Fax

Declaration of Consent

I/we consent to the above-listed Vita Health Care clinician(s) sharing relevant health information with the individuals
and organisations identified in this form. I/we understand that I/we may withdraw this consent in writing at any time. *

I/We give consent to my/my child's referral to the above-listed clinician/s to share information, including letters and copies of reports pertaining to myself/my child with the above-listed parties. I/we understand that the information shared will be at the discretion of the relevant clinician. I/we further provide consent for all above-listed clinician/s to discuss myself/my child between them. *

I/We acknowledge that I/we have read and understood the information provided in the "Your Information, It's Private" brochure (available at Vita Health Care reception) and/or the Privacy Policy on the Vita Health Care website.

I/We understand that a confidential health record will be created and maintained, containing information relevant to my/our care. Health records will be retained in accordance with applicable Victorian legislation, including the Health Records Act 2001 (Vic), and relevant record retention requirements.

*

When information may be shared without consent

In certain circumstances, health information may be shared without consent where permitted or required by law, including under the Health Records Act 2001 (Vic).

This may include situations where a patient is unable to provide consent, it is not reasonably practicable to obtain consent from an authorised representative (or no such representative exists), and sharing the information is reasonably necessary to provide appropriate healthcare.

Information may also be disclosed where otherwise required or authorised by law.

Declaration of Informed Consent

I confirm that the above information I have provided is true, complete and accurate. *

Parent/Guardian Signature (if under 16) *

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Patient Signature *

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Date *