Consent form

CONSENT FORM FOR COLLECTION/ USE/ RELEASE OF MEDICAL AND PERSONAL INFORMATION

This field is for validation purposes and should be left unchanged.

YOUR DETAILS

Name

PURPOSE

I have authorised the Company and/or their respective subcontractors, representatives and/or agents) to collect and utilise the medical and personal information related to the Healthy Spine Program. I understand that information relating to my underlying medical condition, weight, height, body mass index (BMI) and other health measurements such as blood pressure, blood cholesterol level, and blood glucose level will be collected and publish for purposes of evaluating and conducting the Healthy Spine Program. By signing this consent form, I agree to the terms and conditions of the Healthy Spine Program.

I understand that the details of the data will be collected and analysed for the purpose of evaluating the effectiveness of the Healthy Spine Program.

CONSENT TO USE PERSONAL / MEDICAL INFORMATION

  • I freely agree to participate in this program and research project according to the conditions in the Participant Information Sheet which I confirm has been provided to me.
  • I understand that my involvement in this study may not be of any direct benefit to me.
  • I have been given the opportunity to have a member of my family or another person present while the study is explained to me.
  • I have been told that no information regarding my medical history will be shared to unauthorised third parties and the results of any tests involving me will not be published so as to reveal my identity.
  • I understand that access may be required to my medical records for the purpose of this study as well as for quality assurance, auditing and in the event of a serious adverse event and I consent to this access.
  • I understand that I am free to withdraw from the study at any stage without prejudice to future treatment. If I decide to withdraw from the study, I agree that the information collected about me up to the point when I withdraw may continue to be processed.
  • I am 18 years of age or over.
  • I consent to my treating Doctor/s being notified of my participation in this study and of any clinically relevant information noted by the trial doctor in the conduct of the trial.
  • I declare that all my questions have been answered to my satisfaction.
  • I have read, or have had read to me, and I understand the Participant Information Sheet, dated 4th April 2023.
I understand and agree that:

(a) This Consent Form is valid as soon as it is signed but that I have the right to revoke it at any time by writing to the Company, except to the extent that the Company has already taken action based on it.

(b) A copy, including photostat, electronic or fax copy of this consent form, shall be considered as effective and valid as the original and I have specifically authorised its use as such.

(c) I shall not hold the Company responsible or liable for the collection, release, use, storage, processing, amendment and transferring of medical and other personal data for the abovementioned purpose(s).

Clear Signature
Name

DECLARATION BY PRINCIPAL INVESTIGATOR (PI) OR CO-INVESTIGATOR (CI)

A verbal explanation of the research project, its procedures and risks has been given to the participant and I believe that the participant has understood that explanation.

Name of PI or CI
Clear Signature

The Principal Investigator or Co-Investigator must provide the explanation and provision of information concerning the research project.

PRIVACY POLICY

The Healthy Spine Program is operated by PainWISE Pty Ltd, Australia.

  1. PainWISE will only collect information that is relevant and necessary to deliver services and support. You do not have to provide the requested information however without this personal information PainWISE may be unable to provide services and/or support to you.
  2. Personal information provided will only be used for the purpose for which it is collected.
  3. If PainWISE has to share information about you to a third party, PainWISE will seek your consent before sharing your information. If a third party discloses information about you to PainWISE, PainWISE. will inform you of this.
  4. PainWISE will endeavour to ensure that personal information held is accurate, complete and up to date. All personal information will be stored securely.
  5. Statistical information may be provided to the relevant funding bodies for the purpose of ensuring that you are provided with a quality service.
  6. PainWISE will not disclose personal information to a third party without your consent, unless required to do so by law or a duty of care. A duty of care means that PainWISE is required to pass on information if they believe that there is a risk of harm to yourself or others.
  7. You have a right to request access to your personal information held by PainWISE and to seek correction of this information if you do not believe it is accurate.
  8. You can make a complaint if you believe there has been a breach of your privacy or confidentiality.

Please contact info@healthyspine.com.au to the attention “The Privacy Officer”, if you have a request related to this policy.

TERMS AND CONDITIONS OF PARTICIPATION

The Healthy Spine Program is operated by PainWISE Pty Ltd, Australia.

  1. This is a voluntary education program to educate you about back pain and ways to maintain a healthy spine. It does not include clinical advice for your health situation and is not a diagnostic program, and you should see your medical practitioner or other health adviser for advice in your situation.
  2. You can stop your participation in the Healthy Spine Program at any time.
  3. Terms and conditions for the online Healthy Spine Program can be found here: https://healthyspine.com.au/terms-and-conditions-of-participation/