<<Miscellaneous:Practice Letterhead>>

I, <<Doctor:Name>>, have explained to <<Patient Demographics:Full Name>> DOB <<Patient Demographics:DOB>> what it will mean for <<Patient Demographics:him/her>> to be on the CVC program.

He is consenting to;
•	The sharing of their relevant health and medical information
•	The involvement of 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 heath 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 	to allow a 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 program?>>
To the sharing of your personal information including relevant health and medical information and data I have outlined? <<Do you consent to the sharing of health information>>
To the use of a nurse coordinator? <<To the use of a nurse coordinator?>>
To the Care Plan that will be prepared as part of your admission to the CVC program? <<To the preparation of a care plan?>>

Substitute Consent:
Name of legally authorised substitute: <<Name of legally authorised substitute (if required):>>
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 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 of Consent: <<Miscellaneous:Date>>

<<Doctor:Name>>                                Signature________________________________