Patient Information and Consent Form
Confirmation you have read the Consent form (PICF)
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Are you providing consent on behalf of:
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First Name
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Last Name
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Gender
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Date of Birth
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9/5/2021 ]
Address
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Email
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Please provide your email address so that a copy of this Patient Information and Consent form can be sent to you for your records.

Phone #
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How did you hear about CA Clinics?
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Medicare card
DVA card
Upload Health Summary
I consent to the above declarations related to my medical treatment at CA Clinics
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I consent to take part in the research study as outlined above and I allow my data to be analysed for research purposes
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Date consent is given
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9/5/2021 ]
Signature
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