This form collects personal information about you for the purpose of delivering care and services. We will not use or release your information for other purposes without your consent. Please note, however, in an emergency, we are permitted to exchange required information with relevant agencies without your consent.

It is your right to withdraw consent at any time and to obtain access to the information we hold about you.

Disaster & Emergency Management: 

The Client has declined the recommendation for the above identified risks.

*Please see Disaster & Emergency Section for signature of acknowledgement.

Personal Care: 

The Client has declined the recommendation for the above identified risks.

*Please see Personal Care Section for signature of acknowledgement.

Oral Hygiene: 

The Client has declined the recommendation for the above identified risks.

*Please see Oral Hygiene Section for signature of acknowledgement.

Toileting & Continence: 

The Client has declined the recommendation for the above identified risks.

*Please see Toileting & Continence Section for signature of acknowledgement.

Mobility & Transfers: 

The Client has declined the recommendation for the above identified risks.

*Please see Mobility & Transfers Section for signature of acknowledgement.

Household Tasks:

The Client has declined the recommendation for the above identified risks.

*Please see Household Tasks Section for signature of acknowledgement.

Home Environment:

The Client has declined the recommendation for the above identified risks.

*Please see Home Environment Section for signature of acknowledgement.

Communication & Sensory Care:

The Client has declined the recommendation for the above identified risks.

*Please see Communication & Sensory Care Section for signature of acknowledgement.

Nutrition & Meal Planning & Preparation:

The Client has declined the recommendation for the above identified risks.

*Please see Nutrition & Meal Planning & Preparation Section for signature of acknowledgement.

Clinical Care:

The Client has declined the recommendation for the above identified risks.

*Please see Clinical Care Section for signature of acknowledgement.

Medication Management:

The Client has declined the recommendation for the above identified risks.

*Please see Medication Management Section for signature of acknowledgement.

Medication Management:

The Client has indicated that they need assistance to pick up medication and has signed to give permission for assistance. 

*Please see Medication Management Section for signature of acknowledgement.

Skin Integrity:

The Client has declined the recommendation for the above identified risks.

*Please see Skin Integrity Section for signature of acknowledgement.

Foot Health:

The Client has declined the recommendation for the above identified risks.

*Please see Foot Health Section for signature of acknowledgement.

Sleep:

The Client has declined the recommendation for the above identified risks.

*Please see Sleep Section for signature of acknowledgement.

Breathing:

The Client has declined the recommendation for the above identified risks.

*Please see Breathing Section for signature of acknowledgement.

Cognition & Behaviour:

The Client has declined the recommendation for the above identified risks.

*Please see Cognition & Behaviour Section for signature of acknowledgement.

Mental Health:

The Client has declined the recommendation for the above identified risks.

*Please see Mental Health Section for signature of acknowledgement.

Carer:

The Client has declined the recommendation for the above identified risks.

*Please see Carer Section for signature of acknowledgement.

I, 

consent to information relevant to the care I receive being made available as outlined below:

Doctor/GP/Specialist

Aged Care Assessment Service 

(ACAS)

Family Member/Next of Kin

Relevant information may be shared with other team members involved in my care

Other

(i.e. Hospitals, specialists, etc.)

Other Service Providers