I have read the Privacy Amendment Act provided and give permission for correspondence to be sent to my referring Doctor and General Practitioner and Insurance Company where appropriate.

I undertake to pay all fees owing to Dr Duckworth, including in the event that liability is denied or any outstanding accounts that have not been paid in full by my insurer.

I also understand that any outstanding monies requiring debt recovery will incur Debt Recovery fees and I will also be responsible for any legal costs incurred.