Patient Declaration, Consent and Financial Agreement
I confirm that the information provided in this document, and any information provided verbally to clinicians at Kaleidoscope Clinic, has been completed honestly and to the best of my knowledge and ability.
I understand that accurate and complete information is important for safe and appropriate clinical assessment, diagnosis, and treatment planning. I acknowledge that incomplete or inaccurate information may affect the quality or appropriateness of care provided.
Acknowledge and Consent to Communication
Where relevant to patient care, I consent to Kaleidoscope Clinic clinicians communicating with appropriate professionals, which may include:
referring doctors or specialists
psychologists or allied health professionals
relevant healthcare providers involved in care
This communication may include clinical summaries, reports, or recommendations necessary to support patient care.
Telehealth Consent (if applicable)
Where followup appointments are conducted via telehealth, I consent to the use of secure video or telephone consultation for clinical care.
I understand that:
telehealth consultations may have limitations compared with in-person assessments
privacy cannot be absolutely guaranteed in remote environments
the clinician may recommend face-to-face review where clinically necessary
Financial Consent
I acknowledge that Kaleidoscope Clinic is a private billing clinic.
I understand that:
consultation fees are payable in full at the end of the appointment unless otherwise arranged in advance
Medicare rebates may apply to eligible services and are typically processed after payment
any out-of-pocket gap fees remain the responsibility of the patient or parent/guardian
I accept financial responsibility for all consultation fees, assessments, report preparation, and other services provided for the patient.
Where written reports, letters, or documentation are requested or required, I understand that additional report preparation fees may apply depending on the time required.
I acknowledge that reports may take time to prepare following the consultation, particularly where comprehensive developmental or diagnostic assessments are involved.
