Consent form - RehabDynamics

Please confirm your choice of provider: *

I understand I have a choice to nominate my own rehabilitation provider and I nominate RehabDynamics to be my provider.

Please acknowledge the authorisation below: *

I authorise RehabDynamics to obtain information either verbal or written, in relation to my rehabilitation from relevant parties including but not limit to: treating partitioners, employer, insurance company and solicitor. I authorise RehabDynamics to release information concerning relevant aspects of my rehabilitation program to and discuss that information with relevant parties including treating practitioners, employer, insurance company and my solicitor. The information provided will be of a factual nature concerning the rehabilitation program and a copy of any relevant written report may be provided. I understand that this consent is required to assist with my rehabilitation and that all information obtained is treated in confidence. I also understand that I may change or cancel this authority at any time.

Name *

First

Last

Contact (Email or Phone number) *

Date of birth *

Insurance Company

Claim Number

If available

Claimant Signature *

Clear Signature

Please sign your name using your mouse (desktop) or touchscreen (mobile device)

Date *

Date of Claimant signature

Interpreter Signature (if applicable)

Clear Signature

Please sign your name using your mouse (desktop) or touchscreen (mobile device)

Interpreter's name

First

Last

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