<PracticeLetterhead>

I <DrName> have explained to <PtFullName> DOB <PtDoB>, what it will mean for <HimHer> to be on the CVC Program.
<HeShe> is consenting to:
•	the sharing of their relevant health and medical information
• the involvement of the nominated nurse coordinator
• the Care Plan that will be prepared as part of the enrolment in the CVC Program.

Their relevant  health and medical information will be shared with their health care providers as follows:
• health care providers include specialists, pharmacists, allied health, community nurses, hospital   discharge planners, assessors/providers of social assistance and nominated carers
• regular reports on all DVA paid treatments and medicines will be provided to the GP
  this will allow a shared holistic understanding of their condition
• privacy principles and legislation will be observed by all recipients of the information.

Informed Consent

Do you consent: 
• To participating in the CVC Program?  <Do you consent to participating in the CVC Program>

•	To the sharing of your personal information including relevant health and medical information and data       as I have outlined? <Consent sharing of personal, health and medical Information> 

•	To the use of a nurse coordinator?         <Do you consent to the use of a nurse coordinator>

•	To the Care Plan that will be prepared as part of your admission to the CVC program? <Do you consent to a care plan as part of admission?>
Substitute consent :
Name of legally authorised substitute: <Name of legally authorised substitute>
If the person is unable to provide informed consent, a person who is legally authorised to give substitute consent to treatment under state law (e.g. Public Trustee, guardian, holder of an appropriate Special Power of Attorney) may consent on their behalf.
Note: If consent is not obtained, they cannot be enrolled on the program.

Patient/ Legally Authorised Person       Signature: ______________________________   

Date: <Date of consent>

Doctor's Name: <DrName>                      Signature: ____________________________________