Patient Consent

If the Patient:

• has legal capacity to understand and grant their consent to us using this Consent Form, the Registration, and the Patient Terms, but does not have the physical capability to do so independently, the Patient may nominate another person to complete this Consent Form on their behalf. Such person will be the Patient’s ‘Signatory Nominee’ as indicated in the ‘Nominee declaration’ section of this Consent Form; or
• does not have legal capacity to understand and grant their consent to us using this Consent Form, the Registration, and the Patient Terms, our Services may be sought on behalf of the Patient by another person. Such person will be the Patient’s ‘Legal Nominee’ as indicated in the ‘Nominee declaration’ section of this Consent Form,

(such persons are referred to as the Patient’s ‘Nominee’).

For the purposes of this Consent Form and the Patient Terms, obligations on a Patient in the circumstance where the Patient has a Nominee will be interpreted also as an obligation on the Patient’s Nominee, and rights exercisable by a Patient under this Consent Form and the Patient Terms may be exercisable by a Nominee on the Patient’s behalf.

To the best of your knowledge any information you have provided is true and accurate, and you will update such information held by us as it becomes out of date.

Please refer to cann Charitable Trust Privacy Policy here (‘Privacy Policy’) for more information about how we collect and handle personal information. A print version of this is available on request.

For the purposes of this Consent Form please be aware:

• We collect your personal and health information directly from you, your Nominees or through third parties such as your GP or other health service providers to provide our Services, and for other purposes explained in the Patient Terms. If necessary, we may collect information from any other party you authorise.
• You may be asked to complete questionnaires, provide evidence and/or confirmation of diagnosis for us to determine your eligibility to receive our Services in accordance with the Patient Terms. Clinicians in our Clinical Allied Neurological Network (‘Allied Clinicians’) may also conduct health assessments through questionnaires, physical exams, outcome measures, and follow-up reviews. We collect, use and share your information as needed for these reasons or any other reason you have consented to, and to the extent the law allows us to do so.
• We collect your personal and health information including your contact information, the contact information of your Nominees, your healthcare providers, and your medical history.
• We may share your information with our necessary personnel, Allied Clinicians and any of your clinicians helping with your treatment plan. We may share your information in accordance with the Patient Terms, this Consent Form, Privacy Policy, or otherwise with your permission, or if we are not prohibited from doing so.
• You can choose not to give us your personal information, but it may hinder our ability to provide our Services to you.
• We provide no guarantee that you will receive our Services upon your Registration. Support and services are subject to availability.
• To the maximum extent permitted by law, our liability to you is limited to 100% of what we have paid to healthcare providers to support your treatment in the last twelve (12) months.

As the Patient’s Signatory Nominee you declare:

•    The Patient has read (or you have read to the Patient) the Patient Terms and this Consent Form;
•    The Patient has authorised you to sign this Consent Form and complete the Registration on the Patient’s behalf; and
•    You will assist the Patient to the best of your abilities where requested by the Patient in completing any obligations or exercising any rights under this Consent Form or the Patient Terms.

As the Patient’s Legal Nominee you declare:

• You have legal authority to complete the Registration for the Patient and execute this Consent Form;
• To the best of your knowledge any information you have provided regarding the Patient is true and accurate, and you will to the best of your ability update such information held by us as it becomes out of date;
• To the extent applicable, you will provide us with copies of the Patient’s fully executed Enduring Power of Attorney in Relation to Personal Care and Welfare and the contact details of the persons who have been appointed as the Patient’s attorneys; and in certain cases on request we may ask you to provide the Enduring Power of Attorney in Relation to Property
• You will where appropriate complete any obligations or exercise any rights under this Consent Form or the Patient Terms on the Patient’s behalf

As the patient or Nominee you consent to the cann Charitable Trust’s collection, use and disclosure of my personal information and health information in relation to the provision of the Services in accordance with the Patient Terms, this Consent Form and cann Charitable Trust Privacy Policy.

I understand the Services may include cann Charitable Trust’s collection of my personal information including my health information provided by cann Charitable Trust’s Allied Clinicians.
I understand that third party organisations and Allied Clinicians involved in the Services are independent from cann Charitable Trust. cann Charitable Trust makes no representations and give no warranties, guarantees or undertakings concerning their services or engagements with you (including any activity by these third parties relating to your personal information).

I understand that I may accept or decline the gathering of further information, referral to external services or any of cann Charitable Trust’s Services as I choose.

I have read and understood the Privacy Policy provided to me by cann Charitable Trust, the Patient Terms and this Consent Form