You can read the Parental/Guardian GDPR Data Protection Agreement below or View and Download the pdf document

The pdf document can be downloaded here: GDPR Parental Explicit Consent Form D Murgatroyd

GDPR PARENTAL/GUARDIAN EXPLICIT CONSENT
DATA PROTECTION AGREEMENT

         1. Explicit Consent about your Child’s Medical Records

  1. I explicitly consent to you creating and storing medical records concerning the treatment of (print):
  2. ……………………………………………………………………………………, I understand that this may include detailsconcerning medication,
  3. treatment and other issues affecting health conditions, in accordance with the General Data Protection Regulation (GDPR).
  4. I understand that these records will be retained until the child reaches 25, or when the treatment is ceased
    in order to comply with the Institute of Osteopathy legal guidelines. I understand that these records will be
    processed in accordance with your 2018 Privacy Notice, a copy of which I have seen. 
  5. I have read and understood the above information and have the authority to give explicit consent on behalf of the patient:  
  6. Patient’s Name (Print again): ………………………………………………….                   Date:   ………/…………/……………  
  7. –>Your Signature of Consent: ……………………………………………  Print Your Name:………………………………………   
  8. I am acting in the capacity of parent or legal guardian (please state which) …………….……………………………..

        2. Our Communication with you as parent/guardian of this Practice Patient.
      Complete ‘A’ and ‘B’

        ‘A’ – For future appointments and administration (REQUIRED). Your preferred communication route/s
       from us is/are (Tick one or several):

       PLEASE TRY TO INCLUDE ‘MOBILE PHONE & TEXT’ AND ‘LANDLINE PHONE’ (for reasons of speed if urgent) 

[ ] Mobile phone & Text                                              [ ] Landline Phone – Home or work

[ ] Email                                                                         [ ] Post

[ ] Other (please state) ……………………………..

‘B’ – Promotional Information – This is an ‘opt-in’, you can change this at any time by eg emailing us

For the purposes of promoting healthcare including newsletter, offers and advice the Practice would also like to
stay in touch with you, with information that may be of interest to you.

For providing promotional information you can stay in touch with me using the following methods
(Tick one or several):
[ ] Mobile Phone, including Text                              [ ] Email                                                                      

[ ] Post                                                                            [ ] Other (please state) ……………………………………

[ ] None, no promotional information

 

–> Signed: ………………………………………………………….                 Date: ………/……………/…………

 

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