Required fields are marked with an asterisk (*)

Information disclaimer and consent

While Queensland Health endeavours to ensure that the online transmission of the form, containing your information, over the internet is secure, the inherent nature of the internet means that there is a potential risk that your information may be viewed or intercepted by third parties.

Accordingly, submission through the online form shall be at your own risk and Queensland Health accepts no responsibility or liability for any unauthorised access to your information contained in the form when it is submitted online over the internet.

It is inadvisable to complete this form on a public or shared computer. If a public or shared computer is used then this shall be at your own risk, and you must take all reasonable steps to ensure your confidential information does not remain on the computer or in any way accessible by a third party.

Individuals who submit the form online should receive an acknowledgement from Queensland Health that the Form has been sent, on the screen, following submission. Queensland Health accepts no responsibility or liability if this acknowledgement does not appear or we do not receive your online submission.

You acknowledge that you have read and understood Queensland Health’s Privacy Statement and Disclaimer.