RTW Consent Form

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This field is for validation purposes and should be left unchanged.
First Name*
Last Name*
Emergency Contact First and Last Name*
Emergency Contact Phone Number*
Consent*
I authorise Recovery Partners to obtain and release information regarding my injury with the nominated people below to ensure a safe and durable return to work.
Doctor
Specialist
Employer/Employer Representative
Broker
Insurer
Physiotherapist
Exercise Physiologist
Psychologist
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. The scope of this authority to release medical and personal information is limited to the related injury only. I understand that I may withdraw or amend this authority at any time.*

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.

The scope of this authority to release medical and personal information is limited to the related injury only.

I understand that I may withdraw or amend this authority at any time.
I agree with an interim rehabilitation goal of:*
- Same Job / Same Employer
- Similar Job / Same Employer
- New Job / Same Employer
- Same Job / New Employer
- Similar Job / New Employer
- New Job / New Employer
Signature*
Date*
Signature
Date