Patient Consent Form

1. Consent to healthcare services

I consent to receiving healthcare services from Leafwise Clinic Pty Ltd (trading as Leafwise) and its practitioners. I understand that my practitioner will assess my individual circumstances before recommending any treatment, investigation, referral, monitoring or follow-up appointment.

I understand that healthcare outcomes cannot be guaranteed; recommendations are based on the information available at the time of consultation; and my treatment plan may change as new information becomes available. A consultation does not guarantee a particular treatment or outcome.

2. Informed consent

I acknowledge that my practitioner has explained the proposed consultation and treatment process, including the potential risks, benefits and alternatives relevant to my care. I have had the opportunity to ask questions and my questions have been answered to my satisfaction.

I understand that I may ask for further information, decline a proposed treatment or withdraw my consent. My practitioner may ask for additional, treatment-specific informed consent before any particular treatment or procedure proceeds.

3. Telehealth consent

Where my consultation takes place by telephone or video, I consent to receiving care by telehealth. I acknowledge that telehealth may not be suitable in all circumstances and that a remote assessment has limitations. Technical issues may affect the quality of a consultation, and my practitioner may recommend an in-person appointment where clinically appropriate.

I understand that telehealth carries privacy and cybersecurity risks despite reasonable safeguards. I will make reasonable efforts to attend from a private place and use a suitable device and connection. If the connection is interrupted, the clinic may attempt to reconnect or contact me using the details I have provided.

Telehealth is not an emergency service. In a medical emergency, I should call 000 or attend the nearest hospital emergency department.

4. Collection and use of personal information

I consent to Leafwise collecting, storing and using my personal and health information for the purpose of providing healthcare services, maintaining clinical records, coordinating my care, billing and Medicare processing where applicable, and meeting applicable regulatory obligations.

My information will be handled in accordance with applicable Australian privacy and health information laws and the Leafwise Privacy Policy. I understand that information may also be used or disclosed where required or authorised by law, including where necessary to address a serious threat to life, health or safety.

5. Communication consent

I consent to Leafwise contacting me by SMS, email or telephone using the details I have provided for communications relating to my care. These may include appointment reminders, clinical correspondence, referral updates and billing notifications.

I understand that email and SMS may not be fully secure. These routine communication channels are not suitable for urgent medical concerns. Consent to care-related communications does not constitute consent to marketing communications, which are addressed separately.

6. GP and specialist communication

I authorise Leafwise, where clinically appropriate, to communicate and share relevant information about my care with my general practitioner, specialists, allied health providers and other treating healthcare professionals to support safe and coordinated care.

I may tell the clinic if I do not wish it to contact a particular provider. Leafwise will record my preference, subject to any applicable legal or professional obligations.

7. My Health Record

I consent to Leafwise accessing my My Health Record where clinically relevant and uploading clinical information to My Health Record where appropriate and permitted. I understand that access and uploads are subject to applicable law, access settings and clinical judgement.

8. Real-time prescription monitoring

I understand that my practitioner may access real-time prescription monitoring systems where required or permitted by law as part of safe prescribing and clinical care.

9. Prescriptions

I understand that prescriptions are issued solely at my treating practitioner’s discretion following an appropriate assessment. A consultation does not guarantee a prescription, and ongoing reviews or monitoring may be required before or during treatment.

If medication is prescribed, I agree to use it in accordance with my practitioner’s instructions and to raise any concerns or side effects with my treating practitioner or pharmacist. Where applicable, I may choose to take an electronic prescription to a pharmacy of my choice; any dispensing or delivery arrangements will be discussed separately.

10. Financial consent

I acknowledge that consultation fees have been explained to me or made available before my appointment. I understand that Medicare rebates are not guaranteed, I remain responsible for any outstanding fees, and cancellation fees may apply under the clinic’s applicable booking terms.

Medication, dispensing or other third-party costs may be separate from consultation fees. I may ask Leafwise to clarify any fees before proceeding.

11. Medicinal cannabis-specific consent (if applicable)

If medicinal cannabis is discussed or prescribed as part of my care, I acknowledge that medicinal cannabis products may be unregistered medicines and that suitability must be assessed by my treating practitioner. No particular benefit or outcome can be guaranteed, and side effects may occur.

I understand that driving laws and workplace policies may apply. I agree to disclose all medications I take and my relevant medical history so that my practitioner can assess potential risks and interactions. Any decision to prescribe remains at my practitioner’s discretion and may require further discussion and specific informed consent.

12. Privacy Policy acknowledgement

I confirm that I have been provided access to the Leafwise Privacy Policy and understand how my personal and health information may be collected, stored and used. I may contact Leafwise if I have questions about its privacy practices or wish to request access to or correction of my records.

13. Patient declaration

I declare that the information I have provided is accurate and complete to the best of my knowledge, and that I have disclosed my relevant medical history, medications and other information relevant to my care. I understand that withholding information may affect clinical assessment and treatment decisions.

I have read and understood this Patient Consent Form, have had the opportunity to ask questions, and consent to healthcare services provided by Leafwise Clinic Pty Ltd and its practitioners as described above. I understand that I may contact Leafwise at info@leafwise.com.au with questions about this consent.