Patient Name: Unit No

Patient Name: Unit No.

By completing this form you are asking us to make information from your renal records available on the Internet via PatientView. This information may come from:

• your existing computer record held in your renal unit
• other relevant national healthcare-related systems, such as UK Transplant

Once you have completed and returned the form below, you will be issued with a username and password (by post). You will then be able to access this information from any Internet-connected computer, whilstyour GP and some staff from your renal unit, will also be able to view it.

You can choose to show it to anyone else by using your password.

Your information will not be made available on Patient View without your permission. If you decide not to join, or wish to withdraw, it will in no way, have any affect on your treatment.

Important information about Security

Patient View should make it much easier for you to get test results and other information, whilst we hope and expect that it will be very helpful. However, it is important to think about any possible risks of making your information available in this way.

Privacy and security:

To protect your information, we use two methods:

• Every time any information is sent across the Internet, it is coded. The codes used are almost impossible to break.
• Everyone using the system will have their own username and password. The first time you use the system, you will be asked to change your password from the one provided, so that only you know it. It is important to keep your password safe, but you can choose to share your password with other people that you trust. You can change your password at any time if you think someone else may have discovered it.

Together, these create a very safe system. Supermarkets use the same kind of system to make Internet shopping safe. However, it might be possible for a determined ‘spy’ to break into the system and to find your information. They might, for instance, learn your password.

If this worries you a lot, you should not join in.

Please note:

• The system does not show all results but only certain, selected data from blood tests, which are most relevant in the collection and presentation of results for renal diagnosis patients.
• Your GP will also be able to see your information. So will some staff from your renal unit (they can already see it on hospital computers).
• None of your information goes onto the Internet unless you sign up for this project.
• You can choose to leave the project at any time, and your information will be removed.
• All renal units do their best to be sure that all of the information they hold is accurate. However, if you do spot any errors, please contact us and ask for changes to be made.
• If sent by post, your username and password may take up to a week to reach you. Please contact us if it does not arrive after this time.

Any questions?

With this information sheet you should have received other information about PatientView and what it can do. If you have any more questions, here are some people to contact:

Please keep these pages of information and contacts, should you have any questions later.

By signing this, I am stating that I understand the information I have been given, about the security of my computer-held clinical information, as well as the fact that only the most relevant blood test results will appear.

I would like access to my information on the PatientView website.

Print Name………………………………………………….…………………...

Signed………………………………………Date...……………………

Email address …………………………………………..….…………………...

Witnessed by

(This should be completed by a staff member. You should know or be able to confirm the identity of the patient.)

I confirm that the patient has been given a copy of the security and contact information and has seen examples of the information that may be accessed.

It is helpful to check that the name, contact details, NHS No and GP are correctly recorded on the electronic record before anyone joins PatientView.

Signed…………………………………………………. Date………….….……….

Print name…………………………………………….. Position…………………

Aintree University Hospital Nephrology Services page 1/3