Online Consent Form Email * Some Personal Details Name * Mr.Mrs.Ms. Date of Birth * Address * AustraliaAfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaireSint EustatiusSaba BosniaHerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarrussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, British Virgin IslandsU.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Phone * Emergency Contact Name * Emergency Contact Phone * DVA card number * DVA card colour * Consent Form Purpose This form is used as a waver prior to participating in the service and also to confirm that you consent to your treating service provider disclosing relevant information about your medical conditions to Telstra Health and ‘HealthNow’ being the suppliers of Telstra Health Products. You acknowledge this information is required to submit referral request/s to HealthNow doctors so that they may assess and confirm your eligibility for the health care services sought by you. Acknowledgement You acknowledge the following criteria for provision of the Services as set out below: 1. You acknowledge HealthNow doctors are responsible only for undertaking a standard assessment of your health care needs relevant to the provision of the Services with a view to assessing your eligibility, and that such assessment will be based on the information provided by you in your Referral Request. 2. You acknowledge that HealthNow is recognised by the as the usual GP for referrals. 3. You acknowledge HealthNow may require you to attend a TeleHealth appointment if more information is required in order to adequately assess your eligibility for the Services. 4. You acknowledge that the practitioner will record and store notes, medical information, and other pertinent information related to services received as required by ESSA, DVA, Medicare or any other relevant body NOTE: You can withdraw you consent at any time by advising HealthNow or your service provider. Important Information: i) You aware that the facilities and services used involve risk, included but not limited to, risk of bodily injury; (ii) You have provided all the relevant information regarding my medical history and current health status; (iii) You assume (iv) Your personal information is protected by law (including the Privacy Act 1988) and is collected by the service provider and HealthNow for assessment and administration and provision of Services to you. NOTE: All enquries to change or cancel appointments are to be directed to Customer Support on 1300 890 507. I have read and understand the above consent form and agree to these conditions. Signature * Upload referral/other relevant documents Date (Please use date format DD/MM/YYYY )
