Parent/Carer Details

Child's Details

If you are providing consent on behalf of a child please complete the section below. You must be the parent and/or legal guardian of this child.

Third Party

Consent to Release Information

All personal information gathered by South Australia Speech and Hearing Centre Pty. Ltd. during the provision of Allied Health Services will remain confidential.

By completing and signing this form I acknowledge and give my consent to share this information with the third party who's details I have included in this form.

This consent is given on behalf of my child or child for whom I am the legal guardian.


have read, understood and agree to the above conditions, and as the authorised person, agree to give consent to share information regarding the child in question.

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