P: 1300 450 424
E: info@lauraobrien.com.au
W: lauraobrien.com.au

New Client Registration Form

Laura O’Brien APD is committed to providing clients with the best possible nutrition care. To do this, it is essential that your health information is accurate and kept up to date. Could you please assist us in this process by completing the following personal and health information:

Laura O’Brien needs to collect information about you for the primary purpose of providing a quality service to you. In order to thoroughly assess, diagnose and provide therapy, we need to collect some personal information from you. If you do not provide this information; we may be unable to treat you. This information will also be used for:

• The administrative purpose of running the practice;

• Billing either directly or through an insurer or compensation agency;

• Use within the practice if discussing or passing your case to another practitioner within the practice for your ongoing management;

• Disclosure of information to your doctors, other health professionals or to teachers to facilitate communication and best possible care for you; and

• In the case of insurance or compensation claims it may be necessary to disclose and/or collect information that concerns your return to work to an insurer or your employer.

We do not disclose your personal information to overseas recipients.

Laura O’Brien has a Privacy Policy. The policy provides guidelines on the collection, use, disclosure and security of your information. The Privacy Policy contains information on how you may request access to, and correction of, your personal information and how you may complain about a breach of your privacy and how we will deal with such a complaint.

You can access a copy of the Privacy Policy here.

To ensure the process of quality treatment provision, information about your assessment results and progress may be given to other relevant service providers, who are involved in your management. These may include your doctor, medical specialists and allied health professionals, teachers, insurers.

You understand that:

• It is your choice as to what information you provide and that withholding or falsifying information might act against the best interests of your assessment and therapy progress;

• You can access your personal and treatment information on request and if necessary, correct information that you believe to be inaccurate; and

• If in exceptional circumstances, access is denied for legitimate purposes, that the reasons for this and possible remedies will be made available to you.

EMAIL AND TEXT MESSAGE COMMUNICATION

The risks of communicating by email/text include but are not limited to:

• Email and text can be circulated, forwarded and stored in paper and electronic files;

• Backup copies of email/text may exist even after the sender or the recipient has deleted his/her copy;

• Email/text senders can easily misaddress an email or email can be received by unintended recipients;

• Email/text can be intercepted, altered, forwarded or used without authorisation or detection;

• Employers & on-line services have a right to archive & inspect emails transmitted through their systems;

• Emails and texts may not be secure and therefore it is possible that the confidentiality of such communications may be breached by a third party.
  

Laura O’Brien may conduct telehealth consultations with you via secure video consultation or phone consultation. In the event that this occurs, you acknowledge that:

• Your participation is voluntary.

• You have the right to withdraw your consent.

• You have the right to cease consultations at any stage.

• The procedure for conducting telehealth consultations, which can be accessed here.

• Laura O’Brien, an Accredited Practising Dietitian, will take notes during the consultation.

• Your referring doctor or health professional may be contacted in reference to your treatments.

• Your consent relates to:

  • a period of care which may involve several consultations via telehealth;

  • the sending of information in relation to your dietetic treatment to your nominated email address, which is a secure and safe address that only you have access to;

  • permission for other specified health professionals to be contacted in reference to your treatments.
    

24 hours’ notice is required to cancel or reschedule appointments. Providing less than 24 hours’ notice will incur a fee of $50 unless an alternative appointment can be provided on the same day. Failing to attend an appointment without providing prior notice will incur the full cost of the appointment.

Exemptions may apply in extreme circumstances such as illness, injury or death, a car accident or a robbery or assault. Extreme circumstances do not include changes to work rosters, holidays or family activities.

By signing this agreement, I acknowledge that I have read the above information and understand the reasons for the collection of my personal information and the ways in which the information may be used and disclosed and I agree to that use and disclosure. I have been provided with or have been given an opportunity to obtain a copy of Laura O’Brien’s Privacy Policy. I consent to communication via email where practical for administrative purposes and/or clinical care. I understand that Laura O’Brien will take reasonable steps to ensure my privacy and confidentiality through email correspondence. I understand the risks of communicating via email and that Laura O’Brien cannot guarantee confidentiality of information transferred via email. I acknowledge the fees for cancellations and missed appointments.