Authority to release client information/record

First Name: *(as per Medicare Card / Legal Name)

Last Name: *(as per Medicare Card / Legal Name)

Date of Birth: *

Phone Number: *

Address: *

Street address *

Suburb *

State *

Postcode *

If your address may have changed since your last appointment at SHQ please provide your previous address:

Street address

Suburb

State

Postcode

I hereby consent to staff at SHQ Clinic releasing information/reports concerning my medical, sexual and reproductive health history and investigation results including STIs and other relevant information to:

Name of selected persons above: *

Contact number and/or email address of nominated person above *

Details of information requested: *Please provide a full description of the information you are requesting (e.g. Date(s) of attendance, service area attended, type of document requested (e.g., test results, summary)

Please upload a certified copy of photo identification (must be dated within the last 12 months) *

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Client Signature *

Clear

Date: *

If you have changed your name or use an alias, please include all known names to assist with locating your records.

The above authority is valid for 12 months post date

Note Regarding Client Confidentiality

SHQ complies with the Privacy Act 1988 (2017) and is committed to protecting client privacy. Our Privacy Statement, available on our website, outlines clients’ privacy rights. In certain circumstances, SHQ clinicians may be required to share information to protect the safety of the client or others. Unless it is an emergency, this will be discussed with the client beforehand.