This form authorises Sydney Psoriasis Skin Clinics to transfer a patient record summary of recent treatment to the practitioner Di Wallace, as taken from records in their file on the patient.
The patient whose details are contained within the form below, acknowledges the following:
- A) I am the patient named below or I am that patients’ parent or legal guardian and I declare that I hold absolute authority to complete this form.
- B) I authorise for a copy of the treatment history summary (excluding any credit card information held on file), as taken from records kept on my treatment, which are owned and held by Sydney Psoriasis Skin Clinics, to be provided to the chosen practitioner stated below, in a form and to the extent that Sydney Psoriasis Skin Clinics deems appropriate on a patient-by-patient basis, so that continued treatment may be undertaken totally under the guidance of that chosen practitioner and using protocols determined by that practitioner.
- C) I understand that the practitioner who I have chosen is an independent practitioner, is not part of the Sydney Psoriasis Skin Clinic business and does not hold themselves out to be such.
- D) I accept that my chosen practitioner may consult with me via Telehealth (Phone, Zoom, Skype, MS Teams etc) and may post products to my address, or I may arrange a face-to-face appointment at an agreed meeting place.
- E) I understand that the transfer of my treatment history summary needs to be effected within 30 days from the date that written notice of this form was provided to me.
- F) I further understand that my signing of this form does not commit me contractually to either commence or continue treatment with the chosen practitioner as I always possess total authority as to my health choices and I can request the chosen practitioner to transfer the records to another practitioner of my choice
- G) Please transfer my recent treatment records summary to the following practitioner:
- Practitioner: Di Wallace – Psoriasis & Skin Clinic – Gosford PH: 0480 609 955 Email: diannewallacepsc@gmail.com. WE WILL FORMALLY ADVISE YOU WHEN THE RECORDS TRANSFER HAS BEEN COMPLETED – To ensure no confusion and duplication of records, please continue to deal with us until you receive formal advice of the transfer.
- I have been treated by Clinical Skin Practitioner: Ms Moree Coburn ATMS4596, Sydney Psoriasis Skin Clinics
- Shop 4, 202 Princes Highway Sylvania NSW 2224
- Ph: 02 9522 2540 www.sydneypsoriasis.com.au
- Email: clinic@sydneypsoriasis.com.au
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NOTICE TO COMMERCIAL ENTITIES:
This form is for Patient personal Use ONLY
Misuse of this form by businesses will be referred to ACMA