Consent to communicate with a family member or friend

Your privacy is very important to us. We will only share information and communicate with a family member or friend about your care needs where you have given us consent to do so.

Those authorised to speak on your behalf will only be contacted if you have given us consent or if you are unable to speak/communicate on your own behalf for any reason. You will always be our first point of contact.

You can provide us consent to communicate with anyone you choose.

To provide consent for us to communicate with an organisation or service provider including your doctor, allied health professional or community care provider please use this form instead.

At any time, you can change, update or withdraw your consent by contacting us on 1800 777 175 or email infoline@mndnsw.org.au. You can view our privacy policy here or ask for a copy to be posted to you.

Questions marked * will require an answer.

About the Person MND NSW may communciate with

First Name*

Please enter the first name of the person MND NSW may communicate with

Last Name*

Please enter the last name of the person MND NSW may communicate with

This person is my*

Please choose

If Other, please type relationship name

Invalid Input

This person is also my Primary Carer*

Please choose if this person is your primary carer

Contact details for the person above who MND NSW may communicate with

Mailing Address

Please enter letters and numbers only

Suburb/Town

Please type only Letters

Postcode

Please only type numbers

Invalid email address.

Phone (Home)

Please type numbers

Phone (Work)

Please type numbers

Phone (Mobile)

Please type numbers

Your details (the Participant)

Title*

Invalid Input

First Name*

Please type your First Name

Last Name*

Please type your Last Name

Date of Birth*

Please enter your Date of Birth

Suburb/Town*

Please type your Suburb/Town

Postcode*

Please type your Postcode

Home Phone

Please type numbers

Mobile

Please type numbers

Email*

Invalid email address.

Details

Name of person completing form if not Participant

If you are completing the form to assist the participant, please type your name here.

Security*

Invalid Input

Consent to communicate with a family member or friend