Patient Consent for Leukaemia Foundation Cancer Concierge Pilot Program
The information I have supplied to the Leukaemia Foundation via the Cancer Concierge Assessment Form page I hereby declare is true and correct.
I have answered the questions to the best of my ability and understand that my Blood Cancer Support Coordinator (BCSC) and the Cancer Concierge program will not provide me with medical advice at any time.
The Leukaemia Foundation of Australia (Leukaemia Foundation) operates in accordance with the Australian Privacy Principles.
During the course of the Cancer Concierge program, I consent to the Leukaemia Foundation collecting, using and disclosing personal information about me, including:
a. my name and contact details;
b. health information and other information about the progress of my program including notes, programs, assessments and images;
I understand that should I choose not to provide this information, the Leukaemia Foundation may not be able to provide me with the service I require.
I understand that where possible, the Leukaemia Foundation will collect personal information directly from me, however on occasion, it may need to collect personal information about me from my treating specialist.
I understand that the Leukaemia Foundation collects the above information for the purposes of:
a. providing me with services under the Cancer Concierge program and monitoring my progress in that program;
b. providing information about other services that the Leukaemia Foundation may provide;
c. conducting research in relation to the Cancer Concierge program
I agree that in order to provide me with services under the Cancer Concierge program, the Leukaemia Foundation may have to disclose my personal information (including my health information) to my treating healthcare professionals. This will ensure they are aware of my intentions to undertake this program, and that they provide recommendations regarding any special considerations that they feel are applicable to my participation. I understand that de-identified data will be collected throughout the course of the program and will remain the possession of Leukaemia Foundation.
I also agree and consent that my de-identified data from may also be used by the Leukaemia Foundation to for the purposes of research under the Cancer Concierge program.
Consent and understanding
I understand that I am undertaking all activities and programs at my own risk, and that Leukaemia Foundation and my BCSC are not responsible or liable for any injury or condition that may occur during sessions or any loss or damage and including activities performed at home outside of a Cancer Concierge program session.
I hereby voluntarily consent to my involvement in the Cancer Concierge program. I acknowledge that the nature, purpose and risks of the project and alternatives to participation, the details of the intervention proposed, the anticipated length of time it will take and the frequency with which the intervention will be performed, have been fully explained to me by the Leukaemia Foundation. I freely agree to participate in this project according to the information which I confirm has been provided to me by the Leukaemia Foundation about the Cancer Concierge program. I understand that my involvement in this project may not be of any direct benefit to me. I understand that I am free to withdraw from the project at any stage without prejudice to future treatment. If I decide to withdraw from the project, I agree that the information collected about me up to the point when I withdraw may continue to be processed. I am 18 years of age or over. I declare that all my questions have been answered to my satisfaction.
Leukaemia Foundation Contact details
Address: GPO Box 9954, Your Capital City
Phone: 1800 620 420