INFORMATION AND CONSENT FORM

ASSESSMENT DETAILS
Additional documents provided by examinee:
Service ID: 1082718 Yes ¡ No ¡

Service Type: Assessment Date and Time: 22/03/2023 10:30 AM

Referrer/Client Section: WORKCOVER - QUEENSLAND Reference No: S21WV916413

Examiner: Assoc Prof Gregory DAY Specialty: Orthopaedic Surgeon

PERSONAL DETAILS
Name: Ms Sidhe Lee

Date of birth: 2/01/1983 Age: 40 years Gender: F

Address: QLD, 4209

Home Phone: Mobile: 0477 377 666 Email:

Handedness: Right Left Ambidextrous

CONSENT
I, Sidhe Lee, give consent to undergo this assessment and for MedHealth Pty Ltd (t/a mlcoa) to:
(1)    collect, hold and use my personal and health information for the purpose of this assessment;
(2)    directly access and review my test results (including radiology or pathology) if relevant to the purpose of this
assessment;
(3)    contact my treating medical practitioner(s) /allied health professionals if listed below and, for those I list in the
table below, I give them consent to exchange my personal and health information if relevant to the purpose of
this assessment;
(4)    disclose, to the Referrer, a copy of any document(s) that I provide directly to the medical examiner that the
medical examiner considers to be relevant to the purpose of the assessment; and
(5)    disclose my personal and health information contained in the assessment report to the Referrer named above.
Practitioner Name Name of Practice/Clinic Contact details

I acknowledge that I have: (1) been provided with access to a copy of the mlcoa Information Privacy Statement that
outlines how and why certain personal information about me may be collected, held, used and disclosed by mlcoa;
(2) been provided with access to information regarding the purpose of the assessment so that I understand what I
am consenting to; and (3) had the opportunity to seek further information as necessary from a representative of
mlcoa.  I am aware that I may not record my medico-legal assessment without obtaining prior consent as detailed in 
the mlcoa Assessment Information Sheet.

Signature Name Date

...../...../.....
Legal Status to provide consent if not the person being assessed:

Note: If the person being assessed is not capable of providing informed consent, then consent must be provided
above by either a parent, legal guardian, or a person legally authorised to do so; in which case, please also
state above your legal status to provide such consent on their behalf.
mlcoa representative to complete the following sections
Verbal Consent Obtained
Notes: To be used only when verbal consent has been given because a signature on this consent form could not be obtained
(e.g. due to an impairment or injury, or due to technology limitations with a remote assessment)

I am satisfied that verbal consent has been given by the person being assessed for their personal and medical
information relevant to this assessment to be collected, held, used and disclosed by mlcoa. The examinee has
acknowledged they have had access to information regarding the purpose of the assessment so that they understand
what they are consenting to.

(mlcoa representative name) (date  ( dd/mm/yyyy))

(signature)

Verification of Identity
Yes No

By means of: Driver's Licence Passport Other:

(initials of staff member)

Interpreter Requirement
Interpreter Required: ü No Yes Language:

Interpreter Registration No:

Interpreter Name:
Signature: