Consent for Independent Medical Examination -

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Purpose of Assessment:

Dr Anupam Pokharel is a consultant psychiatrist who has been requested to conduct an independent psychiatric examination for the purpose of preparing a medico-legal report.

This examination is not a treatment consultation. Dr Pokharel is not your treating doctor and cannot provide treatment advice.

Important Information for the Examinee:

Important Information

• This is an independent psychiatric examination.
• Dr Pokharel is not your treating doctor.
• Information discussed during the examination is not confidential between the doctor and the examinee.
• A report will be prepared and provided only to the organisation requesting the assessment.
• Audio or video recording of the examination is not permitted by either party.

Voluntary Participation:

Participation in the examination is voluntary. However declining to participate or declining to answer questions may affect the assessment process required by the referring organisation.

Interpreter RequiredYesNo

Consent: Yes, I agree with the privacy policy and terms and conditions. *

Please check the website psychmedic.com.au for the privacy policy and terms and conditions.

Please confirm the following: I understand this is an independent psychiatric examination. *

Please confirm the following: I understand Dr Pokharel is not my treating doctor. *

Please confirm the following: I understand a report will be provided to the organisation requesting the assessment. *

Please confirm the following: I understand audio or video recording of the examination is not permitted. *

Please confirm the following: I consent to participate in this independent psychiatric examination. *

Signature: Enter your full name.By typing your full name you confirm that you have read and understood the information above and consent to participate in this independent psychiatric examination.