Consent Form

"*" indicates required fields

Disclaimer

I understand information about myself and my disability is collected by Therapy P.L.O.T. in accordance with the Privacy Act 2009 and the information is stored securely as per Therapy P.L.OT.'s Privacy and Information Management Policy. This information is confidential and only shared with others outside the organisation for my benefit and with my permission. This includes my personal information, information about support and therapy I receive, and any photographs or videos taken. I understand that in an emergency or where there is a risk to myself or others this may be done outside written permission.

Consent

I,
give Therapy P.L.O.T. permission to share information about me with the following nominated services or individuals:
Untitled*
Please specify below if there is anyone that you do not wish your care and/or support needs be shared with:
Untitled*
I authorise those services / individuals selected above to release health and other information that may be pertinent to my care to Therapy P.L.O.T. as may be requested.
Untitled*
I understand that unless I advise otherwise in writing, Therapy P.L.O.T will continue to liaise with relevant services / individuals as described above on matters related to my ongoing care.
I understand can withdraw / change consent at any time by informing my Occupational Therapist.
Date*