To care for you, your relative/friend, in the best possible way, the Rest Home will need to obtain certain health information, from various sources. Where possible, we will source this direct from you, or your Advocate. At times we will need to converse with your Doctor, obtain a copy of the Assessment report from the A, T & R Assessment team and when necessary information from other authorised organisations e.g. Work & Income New Zealand, Ministry of Health, the local NASC Agency and Laboratory results.

As well as obtaining information it may be necessary for us to provide information about you to other health professionals/organisations, for them to assist in your care, e.g. Hospital, Speicalists. It is our aim throughout this process to ensure that only the appropriate health information is disclosed to relevant agencies. Within its power all information will be stored by the Rest Home in a safe manner as stated in our policy for Consumer Confidentiality.

We are also requesting to photograph you, or your relative/friend for use on personal nursing records. On special occasions sometimes residents are photographed to record the event.

For us to carry out the above functions and to comply with relevant law in the area of gaining and controlling personal information we require you, or your Advocate, to give their informed consent to allow us to comply with these requirements.

Please fill out and sign the form below:

I , give consent for copies of relevant health information, to be given to or sent from the Rest Home, to enable the appropriate, high quality care of myself/relative/friend.

I understand that this may help with the ongoing care for my relative/myself and that it will be held in accordance with the Health Information Privacy Code 1993.