Consent form (Chinese) - RehabDynamics

請確認您選擇的康復中心 *

本人明白我有權選擇自己的康復中心並同意RehabDynamics 康復動力作我的康復顧問.

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

請確認以下授權 *

本人同意康復中心可以向醫生,雇主,保險公司以及律師索取有關個人康復資料和報告.

本人同意康復中心與醫生,雇主,保險公司以及律師聯絡,作定期有關個人的康復進度報告.

發出的資料是個人康復進度的事實以及康復中心同時可以提供有關的書面報告. 康復中心會確保個人資料絕對保密. 本人明白這份協議是幫助我康復. 本人也明白我在任何時候有權更改和取消這份協議.

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 / 姓名 *

First

Last

Email or Phone / 電郵或電話 *

Date of Birth / 出生日期 *

Insurance Company / 保險公司

Claim Number / 索賠號

If any / 如有

Claimant signature / 索賠人簽名 *

Clear Signature

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

Date / 日期 *

Date of claimant signature / 索賠人簽名日期

Interpreter Signature (if applicable) / 口譯員簽名（如適用）

Clear Signature

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

Interpreter's name / 口譯員姓名

First

Last

English