CONSENT AND AUTHORIZATION FORMhome_admin2018-05-02T10:20:29+00:00 [] 1 Step 1 CONSENT FOR FREE CONSULTATION CONSENT FOR 2 HOURS FREE CONSULTATION I, (name of authorizing person): Understand that 24/7 Home Support And Care Inc.Home Care provider has taken into consideration my best interests in their professional judgementUnderstand that 24/7 Home Support And Care Inc.will only share personal information about me to appropriate authority (the Social Welfare Authority/my family Physician) that is directly relevant to abuse and maltreatment suspected by 24/7 Home Support And Care Inc provider for the purposes of protecting my health and safety.Understand that MY personal information is protected under the Privacy Act. I am aware that every individual has a right to access the personal information about himself or herself and that the information may only be used or disclosed within the conditions set out in that Act.Understand that I may withdraw or amend my consent in writing at any time by contacting 24/7 Home Support And Care Inc. Management.Understand that should I not give consent to the disclosure of information,24/7 Home Support And Care Inc. may still have the authority to share my personal information with the appropriate Authority as authorized under the Privacy Act.Have read the above statements, understand the content of this Consent Form and chose to give my consent voluntarily for 24/7 Home Support And Care Inc. to collect information about me for assessment of my needs for care and support purposes.Understand that agreement will be made between me and 24/7 Home Support And Care Inc.to contract the service provision of my needs after the assessment.Understand that 24/7 Home Support And Care Inc. would need my Permission/authorization to commence my care and support services as agreed upon in the assessment. Name (print) : Signature : Datedate_range If this Consent Form is signed by a Parent/Guardian/Substitute Decision Maker/authorized person, please specify the relationship. Name Signature Relationship: Datedate_range Save Form 24/7 Home Support And Care Inc. A North American Home Support And Care Partner keyboard_arrow_leftPrevious Nextkeyboard_arrow_right FormCraft - WordPress form builder