CONSENT TO RELEASE PERSONAL INFORMATION (PAEDIATRIC)

Parent/Carer Details

Surname *

Given Name *

Relationship to the child (SASHC patient)

Mobile Phone

E-mail Address

Address

Street address

City

State

Postcode

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.

Child’s Surname

Given Names

Date of birth:

I hereby declare that I (please print name), *

am the parent/legal guardian of (please print the child's full name) *

Third Party

Third Party: An individual or organisation involved in the client's care, with whom the client's personal information may be shared, that may receive reports, or that is responsible for funding or payment of services.

(e.g. Hearing Australia, Women's and Children's Hospital, a GP, a specialist clinic, a school, etc.)

Organisation Name *

Full Name of Contact at Organisation *

Third Party Contact Position (e.g. speech therapist, teacher etc.) *

Third Party Phone Number

Third Party E-mail Address

Third Party Address

Street address

Suburb

State

Postcode

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 whose details I have included in this form.

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

Consent

I (please print name in full) *

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.

Signature

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Date