Financial Consent:

I, the undersigned, understand and agree that: 

1. I am financially responsible for all charges related to the services provided by NerveSync Pty Ltd | Perth Migraine Centre, regardless of Medicare or private health insurance coverage. 

2. Payment is due in full at the time of service. Medicare rebates (if applicable) will be deposited directly into my nominated bank account. 3. For Workers' Compensation claims, I must pay the consultation fee in full after the appointment and seek reimbursement directly from my insurer. I acknowledge that reimbursement may not cover the full cost. 4. Privacy & Personal Data: 

• ● My personal information, including photographs/videos taken during consultations, will be collected and stored securely in compliance with privacy laws. 

• ● This media will only be used for medical documentation, treatment purposes, or with my additional written consent. 

• ● I may request access to or deletion of my records, subject to legal obligations. 

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Medicare Claims: 

I authorise NerveSync Pty Ltd | Perth Migraine Centre to release any information necessary to process my Medicare claims. 

Co-Payments and Gap Payments: 

I understand that any co-payments, gap payments, or non-covered services are due at the time of service, unless otherwise negotiated. 

Payment Options:

I understand that NerveSync Pty Ltd | Perth Migraine Centre provides several payment options and that it is my responsibility to discuss these options if I have financial concerns. 

Non-Payment: 

I understand that if my account becomes overdue, I may be charged collection fees, and/or legal fees incurred to collect the balance. I also understand that NerveSync Pty Ltd | Perth Migraine Centre may refuse future services due to non-payment. 

Cancellation Policy: 

I acknowledge that NerveSync Pty Ltd | Perth Migraine Centre has a 2 working day cancellation policy. If I cancel or reschedule my appointment within this period I may incur charges. 

I acknowledge NerveSync Pty Ltd | Perth Migraine Centre has a 7 day cancellation policy for any ad-hoc clinic appointments. If I cancel or reschedule within the 7 day period I will be charged $120. 

Acknowledgment and Consent: 

By signing below, I acknowledge that I have read, understand, and agree to the terms of this Patient Financial Consent Form. A Guardian should be signing onbehalf of the patient if the patient is less than 18 years of age or is medicallyunfit to give consent.

AI Consent:

Purpose of this Consent

At NerveSync, we use advanced tools, including Artificial Intelligence (AI) technologies, to improve the efficiency and quality of your care. This includes AI-based transcription and documentation services such as Heidi and Lyrebird, as well as similar tools we may adopt in the future.

How AI is Used

• Transcription & Documentation: AI tools may listen to, transcribe, and summarise clinical consultations to assist with accurate medical record keeping.

• Speech-to-Text Conversion: Your clinician’s spoken notes may be converted into text using AI transcription services.

• Drafting of Letters/Reports: AI tools may be used to prepare draft correspondence for your treating doctors or other healthcare providers.

Your Privacy & Data Security

• AI tools we use are selected to comply with Australian Privacy Principles (APPs) and, where applicable, HIPAA.

• Recordings or transcripts are used only for your care and are stored securely in accordance with NerveSync’s privacy policy.

• We take steps to ensure AI providers have appropriate encryption, data protection, and confidentiality safeguards. - Data is not used to train public AI models without de-identification.

Your Rights

• Participation is voluntary. You can withdraw your consent at any time without affecting your care.

• You may ask how your information is handled and stored.

• You may request that AI transcription not be used in your consultation; in that case, your clinician will take manual notes.

Risks & Limitations

• AI tools are not a substitute for clinical judgment; all clinical decisions are made by your treating clinician.

• While privacy protections are in place, any transfer of data (including encrypted transfer) carries some inherent risk.

Acknowledgement & Consent

I have read and understood the information above. I understand how AI technologies may be used in my care at NerveSync and the privacy measures in place. I have had the opportunity to ask questions, and all questions have been answered to my satisfaction.