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Information Request Form


Please read this privacy statement before signing:

Pursuant to the Privacy Act 1993, the following is brought to your attention:
a) This form collects personal information about you. The information collected to help clinical staff undertake care and treatment for yourself, manage our contact with you and monitor ongoing quality care
b) The information is primarily for the use of St George's Hosptial. However where required, information will be passed to the Ministry of Health and other government agencies as required by law.
c) The information is collected and held securely by St George's Hospital.
d) You have rights to access to and correction of this information, subject to the Provisions of the Privacy Act 1993 and the Health Information Privacy Code 1994. Should you wish to exercise these rights, please contact the Clinical Records Department St George's Hospital, Private Bag 4737, Christchurch

By ticking the following box, you are confirming the above information is correct and you have read and understand the privacy statement. This action replaces your physical signature according to the Electronic Transactions Act 2002, Section 22



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