Representative Consent

Client Details

Client first name *

Client last name *

Client email *

Client mobile *

Client date of birth *

Client address *

House number and street *

Suburb *

State *

Postcode *

Please indicate if you would like to nominate representatives to receive communication relating to your Hear and Say Service. You will be included in all communications. *

YesNo

Primary Representative Details

Primary representative/carer first name *

Primary representative/carer last name *

Primary representative/carer email *

Primary representative/carer mobile *

Primary representative/carer address

House number and street

Suburb

State

Postcode

Would you like to list an additional representative/carer?

YesNo

Secondary Representative Details

Secondary representative/carer first name *

Secondary representative/carer last name *

Secondary representative/carer email *

Secondary representative/carer mobile *

Sharing of Information Consent

Hear and Say is committed to ensuring the protection of your personal information. The following summary outlines how we collect, handle, store, and disclose your personal information, in accordance with applicable privacy laws and best practice standards.

1. Collection, Use, and Disclosure of Personal Information

We will collect, hold, and use your personal information to provide you with relevant services, including but not limited to:

Early Intervention (Listening and spoken Language Therapy)
Audiological (Hearing) Management
Medical Management
Allied Health Services
Rehabilitation/Habilitation
Speech Pathology
Group programs
Associated Administrative Purposes (such as external auditing)

We may collect personal information from external providers as part of the above services.

2. Protection of Personal Information

We take reasonable steps to ensure that your personal information is protected from misuse, interference, and loss, as well as unauthorised access, modification, or disclosure.

3. Disclosure of Personal Information

We will not provide your personal information to any other individuals or organisations without your prior consent, except where required or authorised by law. However, we may disclose personal information on a confidential basis to the following parties:

Contractors: We may share information with contractors who assist Hear and Say with services such as database management, printing, and mailing.
Overseas Recipients: In certain situations, we may disclose your information to overseas recipients, for example, a medical practitioner in another country, if you are using our health services and reside outside Australia.
Emergency Services: In the event of an emergency, we may disclose your personal information to relevant emergency services personnel.

4. Your Rights

You have the right to request access to your personal information and to ask for it to be corrected if it is inaccurate, out of date, incomplete, or misleading.

5. Consent

I give permission to collect and share personal information with the relevant parties involved. I understand, acknowledge, and agree to be bound by the terms set out in this form. *

I give permission for this information to be shared/distributed via email. *

I acknowledge that I have read the Privacy Policy. *

Name of signatory *

Signature *

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