Form library · MED-003

Consent to treatment and telehealth

Example only. Not legal or clinical advice. Review and adapt before use. Not endorsed by any government agency. This example has not had a separate legal review.

Rules differ by state; check yours.

Australian practices taking consent after they have explained the treatment. The practice runs any phone or video appointment.

The practice explains the treatment, its main risks and other options before the person agrees. Consent can be withdrawn at any time. The person can ask to see a doctor in person instead of by phone or video. The practice runs that appointment. nopen does not provide the call. The form does not cover recording.

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Consent to treatment and telehealth

Example only. Not legal or clinical advice. Review and adapt before use. Not endorsed by any government agency. This example has not had a separate legal review.

Example only. Fictional practice: Example Medical Practice, Subiaco.

Full name

Date of birth

DD/MM/YYYY

Is this appointment by phone or video?YesNo

The practice will explain the treatment, its main risks and other options before I agree. I consent to treatment once it has been explained. I can ask questions or withdraw my consent at any time.I agree to an appointment by phone or video if the practice books it that way. The practice runs the appointment.

The practice will tell you the other options to a phone or video appointment and may ask to see you in person. You can ask to see a doctor in person instead of by phone or video. The practice runs the phone or video appointment. nopen does not provide the call. This form does not cover recording a phone or video appointment.

Privacy: Example Medical Practice collects this information to provide your care. We may share it with the people who treat you. Read our privacy policy at example.com/privacy. Example only: the practice must write its own collection notice. See GEN-002.

I agree to Example Medical Practice collecting the health information on this form for my care.

Fields

Person
Name and date of birth.
Phone or video
Yes or no. This does not book the appointment.
Consent to treatment
A tick. The practice explains the treatment, its main risks and other options first. Consent can be withdrawn at any time.
Phone or video appointment
A separate tick. The practice runs the appointment. The person can ask to see a doctor in person instead. nopen does not provide the call. Recording is not included.
Health information
A tick. The practice collects the health information on the form for care.
Collection notice
A line the practice writes before anyone uses the form.
Signature
Signed on the phone.

Questions

Does this form allow a recording?

No. It does not ask for consent to record a phone or video appointment.

Is the signature legal advice?

No. nopen does not give legal advice on whether a signature meets a rule for your profession. Ask your insurer or adviser if you need that confirmed.