CDM Care Plan Request Please fill out the form below to request a Chronic Disease Management (CDM) care plan from your doctor. You will be contacted when your plan is ready for collection. If you require a doctor's consultation before this can be completed, we will contact you to make a booking. Patient Name(Required) First Last Date of Birth:(Required) DD slash MM slash YYYY Doctor's Name:(Required)Dr. David JaaDr. Ping JaaDr. Paul PaytonCare plan provider details(Required) Practitioner and Practice NameCollection Method(Required)Would you like to collect your care plan, or have it sent direct to the practitioner? Collect from clinic Direct to practitioner Patient Email Address:(Required) Patient Phone(Required)Consent(Required) I agree to the privacy policy.I confirm I wish to communicate with Dr. Jaa's Medical Health via email/text and I understand that: It is my request to use email / text; Email / text is not a totally secure system for sending and receiving information; Any decision to use email / text communication will be documented in my clinical records; Emails may be printed and stored in my clinical records; Text communications may be documented in my clinical records; No emails - either sent by me or the staff member will be forwarded to anyone else with consent of any party; Any decision made by myself to stop the use of email / text will be respected upon written notice. Any resumption will therefore require a new Consent Form; Confidentiality will be respected by staff at all times. I am signing to confirm that I have understood the conditions as set out above and have been made aware of the associated risks with regards to data protection.
