Consent to Transfer Information

To protect your right to privacy, I request your permission for the transfer of relevant and confidential information to and from authorised professionals involved in the provision of care services that you or you child may require.

I hereby agree in regard to the coordination and/or provision of health and personal services care, relevant personal information I have provided to NeuroKids & Beyond regarding the client named below can be transferred and discussed with my referrering professional/practitioner and the following professional listed on this consent.

Please complete the form for us to have consent to discuss/and or request information regarding yourself/or child.

Client Information:

Your Full Name: *

Full Name of Client: *

Date of Birth of Client: *

Client Address: *

Your Best Contact Number: *

Organisations Details of who you give consent for us to request information:

Name of Professional: *

Organisations Name: *

Organisations Telephone Number: *

Organisations Email: *

I give permission for NeuroKids & Beyond to discuss & access relevant information/documents/records from the above mentioned professional involved with myself/or child:

Signature: *

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