Patient declaration for receiving urgent Acupuncture treatment under level 3

Patient declaration for receiving urgent Acupuncture treatment under level 3

 I_______________________________________  to receive urgent treatment from:

Patients Name___________________________________________________

Practitioner’s name__________________________________________________

Clinic name————————————————————————————————-

Urgent care for community allied health is defined as:

• a condition which is life or limb threatening; or

• treatment required to maintain the basic necessities of life; or

• treatment that cannot be delayed or carried out remotely without risk of significant harm or permanent and/or significant disability, or

• where failure to access services will lead to an acute deterioration of a known condition; or

• where delay in access to services will impact the consumer’s ability to maintain functional independence and significantly negatively impact quality of life

Please tick which category you are receiving treatment under.

Signature of Patient______________________________________Date_____________________