ADL Information Consent Form

Name
This field is for validation purposes and should be left unchanged.
I authorise Recovery Partners to obtain and release information regarding my injury with the nominated people below:
Doctor
Specialist
Insurer
Physiotherapist
Other
Other
- I understand that this information will only be discussed with the people mentioned above and that all information gathered will be held in the strictest confidence.
- I understand that I may withdraw or amend this authority at any time.
Name*
Signature*
Date*
Name of Interpreter (If Applicable)
Signature (Interpreter - If Applicable)
Date