info@pentacare.com.au
www.pentacare.com.au
0493270917	
Client Consent Form

I, _____________________ hereby acknowledge that Pentacare Pty Ltd has advised me of the following:

•	•	Pentacare Pty Ltd Privacy and Confidentiality Policy 
•	•	my right to access personal information
•	•	my right to withdraw my consent at any time.

I am aware of, and understand that, the organisation may need to collect and disclose personal information to third parties (as required) in order to provide an improved level of care.

I nominate that my personal information be disclosed only to the person or agencies listed below: (third party groups)
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I understand that Pentacare Pty Ltd must comply with relevant privacy laws and I will contact the organisation immediately if I feel that these laws have been breached.

Name of Client 			Signature  ___________________	Date  ________

Name of Program Supervisor/	Signature ____________________	Date  ________
Case Worker

__________________________________________________________________________

Client Non-Consent Form

I do not give my consent for Pentacare Pty Ltd to collect and disclose my personal information to any third parties.

Name of Client			Signature  ___________________	Date __________

Name of Program Supervisor/
Case Worker	                      Signature ___________________	Date __________