1. I consent to registering for a CleverSleep Medicines Therapy Assessment and
confirm that the benefits of the service have been explained to me.

2. I understand that sections of my health records may be shared with other health
professionals involved in my care.

3. I understand that the pharmacist may refer me to another health professional if
needed and that the referral will include information about my health.

4. I give permission for these individuals to have access to my health records.

5. I understand that the pharmacist may provide a summarised report of outcomes to
Health Authorities for statistical analysis, but any reports will not contain
information that enables my identification.

6. I understand I have the right to exit this service at any time and that doing so will
not affect the quality of care given to me.

7. I understand that the collection, use and storage of this information will at all times
comply with the Privacy Act 2020 and The Health Information Privacy Code 2020

8. I have read and I understand the Health Information Privacy Statement