Resident Consent Form - Collect Information
Dear Relatives & Friends of Buckland
We have recently updated the below consent form for Buckland to collect and use personal information of a resident.
If you could please kindly read through and fill in the below consent form and return it to the Nursing Home Reception, alternatively you can email it through to
We will also have copies of this consent form at reception for you to collect from there to fill in.
If you have any questions or concerns, please don’t hesitate to reach out to me on (02) 4752 2500.
Yours Sincerely,
Amanda Penney
Administration / Admissions
Buckland Aged Care
BUCKLAND
CONSENT FORM
TO COLLECT, USE AND DISCLOSE PERSONAL INFORMATION OF RESIDENT FOR THE PURPOSE OF PROVIDING RESIDENTIAL AGED CARE
Privacy Amendment (Private Sector) Act 2000
In order that Buckland can provide you with the quality of care/services outlined in your contract with us, this organisation collects from you as a resident, particular personal information such as your:
- Name
- Date of birth
- Religion
- Current address
- Whether you are a person of Aboriginal or Torres Strait Islander descent
- Other information including entitlement details, health care fund, country of birth
- Medical history
- Medications
- Family medical history
- Social history
- Photographs for clinical (wounds, lesions, etc) or identification purposes (residents, their valuables, etc). This is for residential care residents only.
- Other health care information deemed appropriate
The purpose of this form is to advise you that you may obtain access to the information we hold on you at any time. We also seek your consent to the intended uses and disclosures of that information:
- Other health professionals as required
- As required by other Commonwealth and State Legislation
- To the person you have designated as the “person responsible” for giving and accessing your information.
- Inclusion of photographs and activities program information in displays within the facility, regular newsletters, Buckland social media platforms (Instagram and Facebook) and the facility website. Can include names and date of birth.
It is also important that we outline here what the main consequences may be if you do not provide all, or part of, the information requested.
- Our organisation may be unable to provide appropriate services and care
- Our organisation may be unable to meet the individual requirements of the resident.
I have read and understand the above and consent to the intended uses and disclosures of the personal information that Buckland holds.
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Name (or person responsible): Signature: Date:
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