Patient Consent Form - Chemo At Home

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To receive my chemotherapy, immunotherapy and/or supportive care at home with View Health – chemo@home. I understand that when it is clinically needed, I will attend a health care facility. Examples include, if I have a high temperature, need blood products or need to be reviewed by a doctor.

For View Health - chemo@home to access relevant clinical information related to my care from other health care services/facilities and to share relevant clinical information related to my care with my treating medical team and other health professionals as necessary to ensure I receive appropriate care.

For Patients with Private Health Insurance

In signing this consent, I agree to maintain an appropriate level of Private Health Insurance whilst receiving treatment with View Health – chemo@home. If I do not have coverage at the time of my treatment, I am aware that I will be invoiced for the cost of the home visit as an uninsured patient. If there are any changes to my Private Health Insurance status, I agree to inform View Health – chemo@home before any upcoming appointments.

Cancelled and Missed Appointments Policy

A cancellation fee may be charged if you have confirmed your appointment date and time and later cancel the appointment or are not at home when the nurse arrives. If you need to cancel or reschedule your appointment, please call our office. Please note: In the event that the medication for your appointment has been ordered and the dose prepared in the form ready for administration, you may also be responsible for the pharmacy charges.

Preferred Pharmacy Provider

View Health – chemo@home has a commercial relationship with a preferred pharmacy business, which has a network of pharmacies across Australia that have committed to meet View Health – chemo@home’s service standards, and also with a logistics business that manages complex and time-critical supply chain requirements for chemotherapy and immunotherapy medications. We recommend that you acquire your prescription medications from the nearest preferred pharmacy to you, which can be determined at the following View Health web page: Preferred Pharmacy Disclosure - Chemo At Home.

The logistics business will pay us a commission when this occurs.

If you do not want your medications dispensed by our Preferred Pharmacy, please tick to opt-out.

I DO NOT consent to have my medications dispensed by the preferred pharmacy. I will promptly notify the View Health – chemo@home admissions team and contact my nominated pharmacy to arrange my own supply of medications.

Optional consent (if you do not wish to provide consent, please tick to opt-out)

I DO NOT consent to photographs, audio and video recordings to be taken and used where necessary to assist communication of clinical situations (e.g. infection, wound) with my treating medical team.
I DO NOT consent to clinical information related to my treatment being used for research purposes and publication. Any information used will have any of my identifying details (e.g. name, hospital record number, date of birth, address) removed. This research includes use of the National Health Identifier Service for survivorship monitoring.

Please note this consent form relates to having your treatment at home. Consent over your choice of treatment occurs during your consultation with your doctor.

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