CSF 001.01

OPTIMUM MOVEMENT CLIENT CONSENT FORM

Please complete all sections below. Please note that consent may be withdrawn/updated at any time. By ticking the box and writing your name at the end of the form you are agreeing that all information listed is correct.

Client's First Name *

Client's Last Name *

Client's Date of Birth *

Parent/Guardian Full Name (if under 18 years)

I DO consent to Optimum Movement contacting my medical practitioner or medical specialist. Please list contact details including address and phone number. *

Yes No

Practitioner's Name

Contact Number

If a child/teen: I DO consent to Optimum Movement contacting my child's school/ education provider. Please list best contact name and number.

Yes NoN/A

School

Teacher's Name

School Contact Number

I consent to Optimum Movement contacting my other health providers (psychologist, speech pathologist, physiotherapist). Please list contact details including address and phone number. *

Yes No

Speech therapist Contact Details

Physiotherapist Contact details

Psychologist Contact details

Other

I DO NOT consent to Optimum Movement contacting the following people/agencies regarding myself/my child:

I consent to Optimum Movement providing copies of my child's reports to the following people: *

Please note that you will be informed before this contact is made. Copies of reports will only be provided to the individuals listed below.

I consent to Optimum Movement discussing results/providing feedback from the assessment /therapy sessions with myself (and child if applicable) present. *

Yes No

I give consent to Optimum Movement to receive Occupational Therapy / Physiotherapy services via Telehealth: *

YesNo

I understand that I may agree or refuse any service or part of a service at any time. I can agree or refuse in writing or verbally:

YesNo

I give consent to Optimum Movement taking photographs of myself/my child to be used in the following circumstances. Please choose all that apply:

CONSENT

A photographic image (including a video recording) which is sufficiently clear to enable you to be identified as an individual is personal information. We have obligations under our Privacy and Confidentiality Policy to ensure that personal information is used and disclosed only in ways which are consistent with the law. Personal information is not disclosed or published unless we have obtained the consent of the individual concerned.

I waive any right that I may have to review or approve the image/s prior to them being used or reproduced.

I give consent to Optimum Movement taking videos of myself/my child to be used in the following circumstances. Please choose all that apply: *

By ticking the box below and inputting your full name below, you agree that the information you have provided is correct and up to date. All changes must be made in person or in writing to Optimum Movement.

I Agree

Client Signature - ( Parent/ Guardian signature if under the age of 18yrs)

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Date

First Name

Last Name

Contact number

Signatures email Address

Optimum Movement Pty Ltd ABN: 74 65911 6803
PO Box 762, Cleveland Qld 4163

Clinic Locations - Cleveland, Varsity Lakes, Minyama

p: (07) 3821 3399 e: admin@optimummovement.com w: www.optimummovement.com.au