Consent form

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1. Consent to share medical information and consult with other doctors

I, ………………………………………………….., hereby authorise Dr. ….…………………… and any other Forrest Medico-Legal Services doctors and any other clinicians directly involved in my healthcare to share between themselves (but not with others) relevant medical information about me (which would otherwise be confidential.

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2. Consent to digital storage of data

I, …………………………………………, hereby authorise Dr.………………………………… and Forrest Medico-Legal Services to store confidential information about me in digital form (e.g. on a computer or server).

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3. Consent to digital sharing

I………………………………………………., hereby authorise Dr. …………………………… and Forrest Medico-Legal Services to share (as described in 1 above and 5 & 6 below) confidential information about me in digital form (e.g. on a computer).

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4. Consent to presence of second clinician:

I, …………………………………………………., hereby give permission for one (male/female – delete as appropriate) doctor or other medical professional to sit in for all or part of my examination by Dr…………………………………………………..

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5. Digital photographs:

I, …………………………………………., hereby give permission for Dr ……………………. and Forrest Medico-Legal Services to use photographs (not including my face) of my injuries for the purpose of training clinical colleagues in the documentation of medical evidence. This may include sharing relevant information between clinical colleagues by electronic means (see I, 3 and 6).

6. Further consent to use of my confidential information:

I understand that under no circumstances will Dr……………………………………… or Forrest Medico-Legal Services reveal confidential medical information which is identifiably about me in any way not expressly permitted by me as above, without further consultation with and without express consent given by me. I give permission for Forrest Medico-Legal Services to keep contact details for me in order to seek such permission in the future but for no other purpose.

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Name Date

Signature

 

I ………………………………………………. (Interpreter) confirm that I have translated the above into a language which ………………………………..understand to the best of my ability.

Name

Signature Date

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