You can read the Patient GDPR Data Protection Agreement below or View and Download the pdf document

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

GDPR EXPLICIT CONSENT
DATA PROTECTION AGREEMENT

         1. Explicit Consent about your Medical Records

  1. I explicitly consent to you creating and storing medical records concerning my treatment, which may include details concerning my medication,
    treatment and other issues affecting my health conditions, in accordance with the General Data Protection Regulation (GDPR).
    I understand that these records will be retained for eight years, (or until I reach 25 in the case of someone aged 16 – 18), when 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.
    I have read and understood the above information and give my explicit consent:
    –> Signed …………………………………………………Print ……………………………………………………..Date ………/………/………
  2.     
  3. If acting in the capacity of a legal guardian for the above consent –

    Please state your role and authority or Position: ……………………………………………………… Date ………/………/………  
  4. Sign Your Name: ………………………………………Print…………………………………On Behalf Of……………………………………..

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

  1. ‘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) ……………………………..     
  1. ‘B’ – Promotional Information – This is an ‘opt-in’, you can change this at any time by eg emailing us     
  2. For the purposes of promoting healthcare including newsletter, offers and advice the Practice  
  3. would also like to stay in touch with you, with information that may be of interest to you.    
  4. For providing promotional information you can stay in touch with me using the following methods
    (Tick one or several):
    [ ] Mobile Phone, including Text                                 [ ] Email                                                                         
  5. [ ] Post                                                                               [ ] Other (please state) ……………………………………   
  6. [ ] None, no promotional information   
  7. –> Signed: ………………………………………………………….                 Date: ………/……………/…………

 

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