NerveSync — Patient Financial Consent

1

Patient Details

First Name *

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Last Name *

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Email Address *

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2

Financial Consent

Tick both boxes below to confirm your understanding.

I have read and understood the financial responsibility terms above, including co-payments, gap fees, and the cancellation policy. I am signing as a legally authorised guardian on behalf of a patient under 18 years of age or who is medically unfit to consent. (Tick only if applicable)

Please tick the box above to proceed

3

AI Technology — Information Only

🤖 How NerveSync uses AI

NerveSync Neurology uses artificial intelligence tools to support the delivery of your care. This includes:

Clinical documentation — AI assists in preparing specialist reports, referral letters, and clinical notes. All content is reviewed and approved by your treating neurologist before use.
Patient communications — Our patient portal may use AI to help classify enquiries, draft responses to common questions, and send appointment reminders. All communications are overseen by clinic staff.
Data privacy — AI tools are used in compliance with the Australian Privacy Act 1988. Your identifiable health information is not used to train external AI models.

AI tools do not make clinical decisions. Your neurologist remains solely responsible for your diagnosis and treatment.

✉ If you would prefer that AI tools not be used in your care, please let our team know at reception or email info@nervesync.com.au

4

Declaration & Signature

By signing below, I acknowledge that I have read, understand, and agree to the terms of this Patient Financial Consent Form.

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Patient FinancialConsent Form

Patient Financial
Consent Form