Please Read the Patient & Volunteer Information Leaflet Prior to Completing This Form

Please read the Patient & Volunteer Information Leaflet prior to completing this form.

1.  I agree to my details, including medical information being placed on a secure database within the hospital. /
2.  I understand this consent form does NOT commit me to take part in any research without further information and consent being obtained from me. /
3.  I agree to be contacted periodically to check if I still wish to remain on this database. /
4.  I have read and understood all of the Patient & Volunteer Information Leaflet and understand what is being asked from me on this form. /
5.  I have been provided with contact details to obtain more information or have any questions answered relating to Consent for Contact. /
Question 6 is for Buckinghamshire Healthcare Trust patients ONLY /
6.  I agree to my Buckinghamshire Healthcare Trust health records being reviewed by hospital healthcare professionals ONLY to see if I am suitable to take part in a particular research study.
7.  I agree to my GP being contacted if I decide to participate.
8.  If you are currently receiving any other treatment elsewhere please specify where below and confirm that you give permission for us to access those medical notes.
Please specify: …………………………………………………………………….. /

YOUR DETAILS

Name:
Address:
(Please include postcode)
Gender: / Male / Female / Prefer not to say / Date of Birth / DD/MMM/YYYY
Email:
Telephone:
Mobile:

ADDITIONAL INFORMATION

(You do not have to complete this section but may help us find suitable research projects for you to participate in)

Smoker: / YES / NO / EX
Ethnicity: /
Weight / St lb / kg / Height / ft in / cm
Disability:
Do you consider yourself to have a disability? / YES / NO / If yes, please specify:
Allergies:
e.g. Penicillin, Nuts, etc.
Current Conditions:
e.g. Asthma, Eczema , Diabetes etc.
Current Medication:
Please include any regular prescriptions from your GP – e.g. inhalers, as well as any regular over-the-counter medication you may take.
Signed / Date / DD/MMM/YYYY
To Be Completed by BHT Staff
Hospital Number:*
NHS Number:*

Once completed please return this form to:

Research Office

Old Occupational Health Building

Stoke Mandeville Hospital

Aylesbury Road

HP21 8AL

Contact e-mail:

Phone: 01296 316065