Medical Records - Midfield Meat International

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Medical Records Confidentiality Authorisation Form

I hereby give permission for Midfield Meats Authorised Officers to discuss my drug and alcohol counselling, education and assistance in rehabilitation
with WRAD (Western Regional Alcohol & Drug Centre lnc.),Healthscope,
St johns of Gods Hospital and or other
medical personnel involved in the testing or rehabilitation phase.

Nominated facilities:

WRAD (Western Regional Alcohol & Drug Centre)
172 Merri Street, Warrnambool ph: 1300 009 723

Health Scope (Based at South West Health Care)
Ryot Street, Warrnambool ph: 5563 1515

St John of Gods Pathology (Based at St John of Gods Hospital) 136 Botanic Road, Warrnambool ph: 5564 0660

The Midfield Group as specified below:
- Midfield Meat International sites
- Midfield Meat Processing site
- Midfield Transport site
- Midfield Pastoral sites
- The Meat Barn Midfield Co-Products site
This consent is only valid for the duration of relevant treatment and progress associated with my drug test result dated:*

Day

Month

Year
Employee's Full Name*

First

Middle

Last
Date of Birth*

Day

Month

Year
Phone*
Address*

Address line 1

Address line 2

Town/suburb

State

Postcode

Country
Signature of Employee*
Date*

Month

Day

Year
Witnessed by:

First Name

Last Name
Witness' Signature
Date

Day

Month

Year
CAPTCHA

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