Do you identify as AboriginalTorres Strait IslanderOther
I acknowledge that I may be contacted by email, phone or text.
Dear Patient,Your doctor will make independent professional decisions to optimize your clinical outcome. We value your privacy. All information about I consent to the disclosure of my personal health information by doctors practicing at Maple Street Surgery to other health care providers directly or indirectly involved in my personal health care or medical treatment. I consent to de-identified data (including, without limitation, photographs of my skin and any skin cancers) being used for medical training and medical research by Maple Street Surgery and such data being provided to third parties for these same purposes.
Your personal health information will not be sold by this practice to marketing companies and cannot be used for the purpose of promoting non-health related products or services.
FINANCIAL CONSENT: I have been advised of the estimated costs in respect of the proposed medical services and or had the opportunity to observe same under patient information tab online. I accept responsibility for payment of an account for services rendered, including (if applicable) if a nominated insurer does not pay the anticipated rebate.
PERSONAL DECLARATION: I have read and understood the information provided above.
*(hold mouse then sign)
Signature Patient/ Parent/ Guardian Signature
Print Full Name Patient/ Parent/ Guardian
Have any members of your family had (please X):
The patient named above is now attending Maple Street Surgery. Could you please send us the patients complete file via Medical Objects or fax?
I hereby give my written permission for my records to be released to Maple Street Surgery.
TYPE FULL NAME HERE
NOTE: This is a legally binding document.
Please phone the patient if you require further confirmation.