Under the General Data Protection Regulation (‘GDPR’) there are occasions when D&J Care Service must obtain explicit consent to use your information, known as ‘Personal Data’. Personal Data includes, but is not limited to your name, address, telephone number, and email address. Your Name (required) Date of Birth (required) Address Name of Next of Kin Telephone Number of NOK Address of NOK Email of NOK GP Name GP Telephone Number GP Address I hereby give my permission for D&J care Service to share personal information with other service providers in connection with my care, including accessing and sharing my medical, and if applicable, mental health and Care Plan. I agree to a referral being made to (add local supportive services), in order to support my needs. I understand that (the host organisations) may hold information gathered about me from the various agencies and as such my rights under the Data Protection Act will not be affected. Statement of Consent: • I understand that personal information is held about me. • I have had the opportunity to discuss the implications of sharing or not sharing information about me. To deliver care: YesNo Store personal information: YesNo Sharing personal information: YesNo Contacting family and other professionals: YesNo Call an ambulance consent: YesNo A “best interests” decision has been taken to proceed with the proposed care and treatment, and this is confirmed by the person’s relative/legal representative. The reasons for the decision are as follows. Summary of reasons (together with details of any proposed review, etc) Your consent to share personal information is entirely voluntary and you may withdraw your consent at any time. Should you have any questions about this process, or wish to withdraw your consent please contact: (Dora Amoako) Name of witness/representative/ or service user: To be signed by a witness/representative/ or service user Relationship to service user: Is an “Advance Decision” in place? YesNo Is there a Lasting Power of Attorney or Equivalent in place? YesNo If yes ensure a copy is placed on file. Manager accepting responsibility for the decision: YesNo Signature Signature Date
