Consent Form

Consent
Form

Your consent is required in terms of collecting, using and disclosing your information. Please read carefully and sign. You can sign digitally on this page below or can also download the form, take a printout, sign and bring it to us.

This document sets out how you consent to the trustee for The AR and NJ Trust ABN 90 695 260 533 operating as Foot Balance Technology (Foot Balance Technology, us, we or our) collecting, using and disclosing your personal and sensitive information.

Please review the following and sign your name in the appropriate column depending on whether you do or do not consent. You may also withdraw your consent at any time by informing us. We understand that your needs may change. You can update these consents at any time by providing this completed page to us again or by contacting us.

For more information about how we collect, use and disclose your personal and sensitive information, you can read our privacy policy here.

COLLECTION OF YOUR INFORMATION

In order to provide you with the goods and services, we need to collect your personal and sensitive information as set out in our privacy policy. By signing below, you consent to the collection, use and disclosure of your personal and sensitive information in accordance with our privacy policy. This includes your health information, medical history (including medical documents) and any support requirements under your NDIS plan (if applicable). This information may be shared with other health practitioners we may refer you to, and manufacturers and other third parties we work with (including overseas) to provide you with goods and services.

MARKETING

By signing below, you consent to the collection, use and disclosure of your personal and sensitive information (including to overseas third parties) for the purposes of direct and indirect marketing.

EDUCATION AND TRAINING

By signing below, you consent to the collection, use and disclosure of your personal and sensitive information for the purposes of education and training. This includes Foot Balance Technology using your personal and sensitive information for internal staff education and training, and disclosing this information to third parties (including those overseas) for their own education and training purposes.

RESEARCH

By signing below, you consent to the collection, use and disclosure of your personal and sensitive information for the purposes of research development. This includes Foot Balance Technology using your personal and sensitive information for internal research and disclosing this information to third parties (including those overseas) for their own research purposes.

RELEASE OF IMAGES, VIDEOS AND 3D SCANS

By signing below, you consent to Foot Balance Technology making an audio and/or visual recording (including a photograph, video or 3D scan) of any part of your participation in the goods and/or services provided by Foot Balance Technology (Media).

You consent and agree that:

  1. Foot Balance Technology owns all rights (including intellectual property rights) in all Media;
  2. to the extent that you may own any, you assign all present and future copyright or any other intellectual property rights owned by you in the Media to Foot Balance Technology;
  3. Foot Balance Technology may use and authorise the use of the Media in whole or part for the purposes set out in this consent document, including for marketing, education, research, training and any other purpose contemplated in this document or Foot Balance Technology’s privacy policy;
  4. Foot Balance Technology may disclose the Media to third parties (including those overseas) for the above purposes; and
  5. Foot Balance Technology may use your name, likeness, voice and biographical material in connection with any use of the Media.

You release and indemnify Foot Balance Technology, its assignees, and licensees from and against any claims arising from any breach of this agreement. You waive any moral rights you may have in the Media and consent to Foot Balance Technology and any of their successors, assignees and licensees, doing all or any acts or omissions which may infringe such moral rights.

AUTHORITY TO CONSENT

By signing below, you represent and warrant that you have the full authority to provide each of the consents in this document because you are the patient or a Representative of the patient. In this document, “Representative” means:

  1. a parent or legal guardian of a patient (if that patient is under 18 years of age); or
  2. a NDIS nominee, support coordinator, plan manager or representative of the patient.
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