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CmyNP

Patient Intake & Consent Form

Complete before or at your first appointment

CMYNP PTY LTD (ACN 697 376 453) · Miss Shari Edwards, Endorsed NP (AHPRA NMW0001666654)

Please complete all sections of this form. It gives us the information we need to care for you safely and tells you how we will use your health information. If you have any questions, please ask before you sign.

CmyNP is a private Nurse Practitioner service. CMYNP PTY LTD has no official financial affiliation with Queensland Health or Correctional Health Services.

This online form stays on this device. Print it when complete, or download the printable version, then return it securely.

Part A — Your details
Part B — Your GP and other treating practitioners

This helps us coordinate your care safely. We will only contact your GP or other practitioners with your consent (see Part D).

Part C — Opioid treatment services (complete if applicable)

Complete this section if you are seeking opioid treatment services (OST) from CmyNP. If you are not receiving OST, you can leave this section blank.

Are you currently enrolled in an OTP with another prescriber?

Part D — Your consents

Please read each statement and tick the box to confirm your consent. If you do not understand something, please ask us before you sign.

1. Collection and use of health information

2. Real-time prescription monitoring (SafeScript NSW and QScript) — only if applicable

Complete this section only if you receive opioid treatment or another monitored medicine. These checks are legally required when relevant to prescribing.

3. Nominated pharmacy and dosing arrangements

4. Coordination with my treating team

5. Emergency contact authorisation

6. Service agreement

Part E — Collection statement (summary)

The following is a plain-language summary of how CmyNP handles your information. Our full Privacy Policy is available at www.cmynp.com.au

About our service
CmyNP is a private Nurse Practitioner service with no official financial affiliation to Queensland Health or Correctional Health Services
Identity and contact details
Name, date of birth, address, phone, email, emergency contact
Health information
Medical history, medications, clinical notes, treatment records, test results
OST-specific information
OTP enrolment, medicines prescribed, dosing arrangements, RTPM records
Government identifiers
Medicare number, IHI — used only for clinical and billing purposes
Financial information
Invoice and payment records used only for billing and practice administration
Identity verification
Photo ID sighted by video at the first consultation (RACGP CG2). If you have just left custody without photo ID, a case manager, parole officer or re-entry worker can sign as custodial witness instead — we note this in your record and never store copies of your ID
Who we share with
SafeScript NSW / QScript (required by law), your nominated pharmacy, your treating healthcare team (with consent), Medicare and pathology services
Retention
Minimum 7 years (adults) from last consultation. Longer for child patients. See Privacy Policy for details.
Your rights
Access, correct and (in limited circumstances) request deletion of your information. Complaints to us or the OAIC (www.oaic.gov.au).
Part F — Declaration and signature

By signing below, I confirm that:

  1. I have read this form (or it has been read to and explained to me) and I understand its contents; the information I have provided is accurate and complete to the best of my knowledge;
  2. I have ticked the consent boxes above that apply to me; and
  3. I understand that I can withdraw any consent or update my preferences at any time by contacting CmyNP.

Patient signature

Signed on behalf of patient (if applicable)

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