• Consent has been given by patient before the submission of this e referral form.
• If under 18, the referral outcome can be discussed with guardian.

The patient (or their guardian or representative) has consented to the collection and disclosure of their personal and health information to the Head to Health Service. They have acknowledged and understand that:

• Head to health may contact them to discuss their referral
• The phone call will come from (07) 3062 8437
• Their personal information will be managed in accordance with the relevant privacy policy and statements, which can be found here: STA-PRI-001v3-Privacy-Statement-.pdf(c2coast.org.au)
• All documents that form part of this referral will be scanned for viruses by third party anti-virus software