Privacy Form That is Signed by Each Patient at First Consultation
Any personal information communicated during consultations is for the sole purpose of providing homœopathic treatment. Any information that I disclose as a client will remain strictly confidential unless I specifically request otherwise, or it is required by New South Wales or Australian Federal law.
Any information disclosed will be protected using appropriate physical, electronic & managerial procedures to prevent unauthorised access and to ensure the information is used correctly.
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I give permission for my practitioner to confer with colleagues regarding my case in order to offer me a better health care service.
Yes / No
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I give permission for my case details to be used anonymously for educational & research purposes, such as a case study as example in a lecture.
Yes / No
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I give permission for the practitioner to pass information to other health professionals if necessary (eg medical practitioner, chiropractor).
Yes / No
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I give permission for the practitioner to record the consultation for educational purposes
Yes / No
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I give permission for monthly newsletters to be sent to my email address
Yes / No