CORPORATE HEALTH CONSENT FORM – Innovate Healthcare

CORPORATE HEALTH CONSENT FORM
First Name:*
Surname:*
Date of Birth:*
Preferred telephone number:*
Preferred email address:*
Enter Email Confirm Email
How we use your information:
In order for Innovate Healthcare to assist you with your rehabilitation needs we may need to obtain information during the assessment regarding your personal situation, medical history, current injury and employment/vocational status.

Once an assessment has been completed, we will write a report detailing the relevant things we have discussed with you and send it to your referring party with the aim of advising them on how they can support you. The report may therefore include impartial advice resulting from the assessment to inform recommendations to support a return to function/work. Calls to/from Innovate Healthcare are recorded for monitoring and training purposes.
Your right of access:
European Regulation provides you (“the Data Subject”) with the right to obtain access to personal data that we hold about you. Personal data is defined as “data from which a living individual can be identified or identifiable (by anyone), whether directly or indirectly, by all means reasonably likely to be used”. You can make a subject access request by writing to Innovate, including your full name, address and contact telephone and include details of the specific information you require and any relevant dates.
I confirm that I understand and agree:
- The reason and purpose of the referral has been explained to me and I am willing to undergo the assessment.
- Following the assessment, a report can be sent to my employer/referring party and I can request to see it if I wish. The report may include independent and impartial advice on topics such as recommendations to support a return to work or stay in work, current fitness for work and the impact of work on any disclosed health conditions.
- That my assessment may include a physical examination and/or tests but these will be explained to me if they are required.
- My personal and medical information will be maintained and processed confidentially by Innovate Healthcare staff, in accordance with the DPA (2018).
- If I choose to see a copy of the report when it is sent to my employer/referrer it will be emailed or posted to me.
- I have the right to revoke my consent at any time. However, any data processing that occurs before consent is revoked will still be valid. I can revoke my consent by writing to Innovate at the address given on this form (via post or email).
Your Consent:
I, _ _ _ _ _ _ _ _ _ _ confirm that I have read and understood this Consent Form and hereby give Innovate my consent to obtain, use and disclose information about me as described in this form. I agree that a copy of this Consent Form will be as valid as the original.
Print Name: _ _ _ _ _ _ _ _ _ _
Date: 21/09/2020
Signature:*
Please choose and tick one of the following options:*
- I agree and consent to the assessment and a report being compiled and forwarded to my employer/manager.
- I would like a copy of the report.
You have indicated that you wish to receive a copy of the report, it will be sent at the same time it is sent to your employer/manager. However, if you wish to have the copy sent before it is sent to your employer/manager, please discuss this with the clinician conducting your assessment and they will organise this for you.