Consent Form — Specialist Plus

Do you identify as:

AboriginalTorres Strait IslanderBothNeither

I CONSENT TO THE FOLLOWING:

Workcover and Motor Vehicle Accident Claimants: I acknowledge that I am responsible for payment of all accounts associated with the treatment of my injury if my insurer or employer suspends or discontinues payments.Specialist Plus recording and sharing information obtained from me: I understand that this information may be shared with laboratories, radiological facilities, other health service providers, rehabilitation consultants, insurers, medical defence organisations, lawyers, or my employer for the purpose of investigation, treatment, and rehabilitation of my injury or illness, unless otherwise specified. I understand that I may revoke this consent at any time in writing.Appointment Cancellations: I understand that if I do not notify the clinic of a cancellation at least 48 hours in advance, I will be charged a cancellation fee.Medical Records Access: I authorise and consent for Specialist Plus to obtain copies of all imaging results, test results, and reports related to my injury.Use of AI Technology in Consultations: Some doctors may use AI technology during consultations to assist with documentation. This software functions solely as a transcription tool and does not store any audio or recordings. If you have any concerns, please speak with the doctor or staff.

Pre-injury Job and Duties

Job TitleEmployerHours per week

Please describe your pre-injury job duties and how do you do it

Are you currently off work?Are you currently on work restrictions?Reduced hours?

If so, please explain below (include hours, work restrictions specified by doctor and description of duties)