The medical centre you will be attending (The Thoracic and Sleep Group Queensland) provides Sleep Study and Respiratory Testing services to it's patients.

As part of these services we require your consent to collect personal information about you for the primary purpose of providing quality healthcare. It may be necessary to obtain further health and/or personal history from other health providers or family members. Your completion of this form implies your consent to the collection, use and storage of this information. 

For detailed information, select relevant fields below. 

Please read this information carefully, acknowledge your consent and sign where indicated.

We require you to provide us with your personal details and a full medical history so that we may properly assess, diagnose, treat and be proactive in your health care needs. This means we will use the information you provide in the following ways: 

• Administrative purposes in running our medical practice, including patient clinical management, quality assurance and practice audits, NATA accreditation reviews, staff training and education. 

• Billing purposes, including compliance with Medicare and Health Insurance Commission requirements. 

• Disclosure to others involved in your health care, including treating doctors and specialists outside of this medical practice. This may occur through referral to other doctors, or for medical tests and in the reports or results returned to us following the referrals.

• Ensure effective communication with Medicare Australia, Private Health insurers and Government departments

By providing your consent, you acknowledge the following:

• I understand that I am not obliged to provide any information requested of me, but that my failure to do so might compromise the quality of the health care and treatment given to me. 

• I am aware of my right to access the information collected about me, except in some circumstances where access might legitimately be withheld. I understand I will be given an explanation in these circumstances. 

• I understand that if my information is to be used for any other purpose other than set out above, my further consent will be obtained ( please consider consent for educational purposes to follow). 

• I consent to the handling of my information by this practice for the purposes set out above, subject to any limitations on access or disclosure of which I may notify this practice.

As part of the Sleep Service, you acknowledge the following:

• I permit a Sleep Study to be performed, including a recording of my digital image ( exclusively during your sleep study), and a copy of the final report be sent to my listed general practioner.

• I understand that by signing this document I am not obliged to undertake this procedure if for any reason I change my mind in the future.

• I understand that the company (The Thoracic and Sleep Group Queensland) may ONLY use the results and digital imaging recording of myself to accurately diagnose and monitor any such sleep disorder that I am suspected of having.
  

• I acknowledge that I am liable for any fee that is not covered by my private health fund and failure to make payments may result in the transfer of the account to a debt collection agency and also be liable for any fees incurred.
  

• I have read and understand supplied documentation provided to me by the Medical Director of the Thoracic and Sleep Group Queensland, that explains the procedures and risks involved in having a sleep study performed and have had the opportunity to ask questions about the procedure.

• I accept any damage done to the equipment due to improper use may incur a fee equal to the costs of repair or replacement of the damaged or lost equipment ( including, but not limited to, water damage, physical cracks or breakages, broken inputs, broken leads or missing equipment).

• During ambulatory monitoring (eg. Home Sleep Study), please note: Thoracic and Sleep Group (Qld) encourages patients to be driven by another person when wearing the sleep study device. The decision to drive while wearing the sleep study device is the responsibility of the patient and the Thoracic and Sleep Group (Qld) will not be held liable for any consequence of driving a vehicle while wearing this device. Due to potential risk of entanglement with sensors attached to the equipment it is advised not to co-sleep with infants, young children or pets during the night of the study. Thoracic and Sleep Group (Qld) will not be held liable for any consequence of such sleeping arrangements.  

As part of the Respiratory  Service, you acknowledge the following:

• I permit Respiratory Testing to be performed, and a copy of the final report be sent to my listed general practioner.

• I understand that by signing this document I am not obliged to undertake this testing if for any reason I change my mind in the future. 
  

• I am aware that if immediate life-threatening events happen during the testing, I will be treated accordingly by an attending Physician/Emergency Nurse.
  

• I was able to ask questions and raise concerns with my referring doctor about my condition, the proposed testing and its risks, and my treatment options. My questions and concerns have been discussed and answered to my satisfaction.

• I  am aware that I can ask questions and raise concerns with the  testing scientist, however I understand that test results and treatment options cannot be discussed during the procedure.

• I have received and read test specific information for my procedure, and acknowledge any risk factors indicated within. 

We respect your rights to privacy and take our privacy obligations seriously. We comply with the Australian Privacy Principles, found under the Privacy Act 1988 (Cth). Our Privacy Policy can be obtained from:

• Australian Privacy Principles - Home (oaic.gov.au)

• Australian Privacy Principles guidelines - Home (oaic.gov.au)

• Main Reception, The Wesley Hospital

• Phone (07) 3870 1120

• Email admin@tsgq.com.au

Witholding consent  will compromise the quality of the health care and treatment we are able to provide to you. Please contact our office if you do not acknowledge the conditions above or authorise release of medical information, (07) 3870 1120.

The Thoracic & Sleep Group Queensland is also involved in the training and education of tertiary and post-graduate students and contributes to the field of medical research. This clinical education and research helps to improve the quality of our service and the field of Thoracic and Sleep Medicine. 

• By chosing to consent to the use of your Sleep Study and/or Respiratory Test results, The Thoracic and Sleep Group Queensland will ensure that any personal information will remain anonymous  (including your name, date of birth, and contact details)  for the purposes of educational and research purposes. Your results will remain solely with The Thoracic and Sleep Group Queensland and your referring doctor/general practitioner.  
  

• By witholding consent, the results of your  Sleep Study and/or Respiratory Test will ONLY be viewed by The Thoracic and Sleep Group Queensland's faculty  and your referring doctor/general practitioner.

This form will be submitted via email to Thoracic and Sleep Group Queensland. A copy will also be sent to the email address provided above.