Patient Authorisation Form

This form gives our clinicans and administrative staff consent to speak to your third parties about your injury. Please read the following carefully.

I hearby give consent for my Construct Health Clinician or administration staff to discuss with nominated Third Parties specific information to assist with my rehabilitation plan and safe return to work. I have been informed that the information discussed is in relation to my current functional limitations and the resultant impact on the inherent physical requirements of my role. I understand that some of the information is collected and may be used for statistical purposes only.

Client First name: *

Last name: *

Date of birth *

Company *Company that you work for (not sub contracted to)

Body Region *

Do you have an open workers compensation claim for this injury? *

YesNo

Please provide workers compensation claim details if applicable (claim number, insurer contact details etc)

Site of Work

Employer *

Health Advisor/ Paramedic *

(Paramedics are included due to most communications channels having a shared email).

Return to Work Co-ordinator

Supervisor

Manager

Doctor

Specialist

Other: Please list below

Who else would you like to be able to access this information on request?

I (the patient) have read this form, understand the information it contains and give my consent to discuss my specific injury/illness information with the parties listed above *

Signature *

Clear

Name: *

Date of consent *The date you were asked to fill out the form.