Callala Bay Pharmacy

Consent Form

Please read each statement carefully and check the box to indicate your agreement. All fields are required.

Patient Details

Full Name*

Date of Birth*

Mobile Phone*

Consent Statements

Please read and check each statement.

I consent to receiving the requested pharmacy service(s) provided by Callala Bay Pharmacy.

I understand the nature of the service, including its purpose, expected benefits, and any associated risks that have been explained to me.

I confirm that the information I have provided about my health, medications, and allergies is accurate and complete to the best of my knowledge.

I understand that I may withdraw my consent and discontinue the service at any time by notifying the pharmacist.

I consent to Callala Bay Pharmacy collecting, storing, and using my personal and health information for the purpose of delivering this service, in accordance with the Australian Privacy Act 1988.

I acknowledge that my information may be shared with other healthcare professionals involved in my care, where necessary and permitted by law.

Declaration

I am completing this form on behalf of another person (parent / guardian / carer).

Signature (type your full name to sign)*

By checking this box and typing my name above, I confirm that I have read, understood, and agree to all the statements on this form. I understand this constitutes my electronic consent.*

This form is provided by Callala Bay Pharmacy. For questions, contact us before your appointment.