Eviole and the Lifeshape Clinic complies with the Privacy Act 1988 as amended (the Act), and the Australian Privacy Principles (APP). In order to protect your privacy as required under the Act and APP, we have a Privacy Policy that is available on our website.

Our policy requires that we obtain your consent to collect your personal information. Please read this form carefully and sign where indicated below.

We collect your personal information for the primary purpose of providing quality health care. We require your personal details and full medical history to assess, diagnose and treat you; and importantly, to be proactive with your health care. This means that we may use your personal information in the following ways:

• Administrative and billing purposes in Eviole and Lifeshape Clinic. This includes sending information via your email address (such as Statements of Service for claiming eligible rebate from your Private Health fund, letters, and marketing updates about our clinic).

• Personal information may be discussed amongst the clinicians involved in your care at Eviole and LifeShape Clinic to optimise your clinical care and the effectiveness of your program.

• Disclosure to and liaison with other parties involved in your health care, including referring Doctors and specialists outside of Eviole. This may occur when we have received a referral from your Doctor and we are required to report your information in return.

• Anonymous disclosure of your results for research and quality assurance This allows us to improve our quality of care, enhance the management of our practice and contribute to community health care initiatives.

• Emergency situations where medical officers or hospitals need your patient notes for treatment

In other situations as required under law, as stated in our Privacy Policy.

Client Statement:

I declare that I have read the information above and understand why my personal information must be collected. I am also aware that Eviole and LifeShape Clinic have a Privacy Policy regarding handling personal information.

I understand that I am not obliged to disclose all of my personal information, but that my failure to do so may compromise the quality of my health care.

I am aware of my right to contact Eviole and LifeShape Clinic and access the information collected about me, except in specific circumstances where access might legitimately be withheld. Those circumstances include, but are not limited to, where there is a serious risk to a patient’s life or health. I understand that I will be given an explanation should these circumstances arise.

I consent to Eviole and Lifeshape Clinic handling my information for the purposes set out above and as stated in the Privacy Policy, subject to any limitations on access or disclosure that I notify this practice of in writing.

I consent to any bulk billing Medicare benefit being assigned to LifeShape Clinic (LifeShape Health Australia Pty Ltd).