E-Consent and Referral

Welcome to Injury Doc NZ

We’re sorry about your injury. Our job is to help get you back up and running as soon as possible. But to do that, we first need your consent so our Injury Doctors can start your assessment and treatment, as well as keep your workplace, Physio, GP, Occupational Therapist and other health care providers in the loop. So please fill in the below E-consent form to get the ball rolling.

Your consent matters

We’re here to support your recovery and safe return to work. This consent allows us to do our job while protecting your privacy. We only share relevant information related to your injury, recovery and return-to-work planning.

If you have any questions, your Injury Doctor will be happy to chat things over during your video call appointment. And if you’re unsure or choose not to consent, please get in touch with your workplace key contact asap and discuss if Injury Doc NZ is the right fit for you as you have an initial appointment booked

Informed Consent Form

Informed Consent Form

Your Personal Details

Name
Name
First
Last
Do you have an Enrolled GP Practice

Enrolled Practice Details

Perferred Pharmacy

INFORMED CONSENT

I give my consent to receive assessment, treatment and management advice from Injury Doc NZ’s clinicians. This includes allowing Injury Doc NZ to communicate with my employer, other healthcare providers, and case managers (like ACC or insurers) through email and calls. These communications are for the purpose of supporting my recovery, co-ordinating rehabilitation, and planning my return to work, including sharing information about any identified health and safety risks related to my work role.

I also consent to Injury Doc NZ clinicians accessing my relevant health information from sources such as ACC, my GP, specialists, other healthcare providers, and electronic health records to support my rehabilitation.

Injury Doc NZ acknowledges and respects my right to control my private health information. I will receive copies of written communications and these will be discussed with me during my consultations.

I understand that I can stop the assessment or treatment at any time or withdraw my consent if I choose.

By signing this digital form, I confirm I have read, understood and agreed to the details outlined above.

Do you need any support from your workplace to access a device for your virtual consultations?

Medications

Please provide the following details of any of your current health care professionals; to allow us to contact them to assist in your rehabilitation - if known:

Name
Name
First
Last
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Was an Interpreter Involved in this consent process?

INTERPRETER’S ASSISTANCE FOR INFORMED CONSENT (to be completed if an interpreter was involved in this consent):

I certify that I am fluent in the language of the person providing consent. I certify that I have accurately and completely interpreted the contents of this form, and that the person giving consent has indicated their understanding of the contents.
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