Patient Sign Up | Rowling CARE

Before completing the online form below, please download and read the following information leaflet:

Rowling CARE Patient Information Leaflet (Patient) v1.0 23rd Nov 2021

Please see our privacy statement for more details of how we use the information we collect about you.

Confirmed reading/understanding of information sheet

1) I confirm that I have read and understood the information sheet (dated 23rd November 2021, version 1.0) for the above study. I have had the opportunity to consider the information and ask questions. (Required)

Confirmed voluntary participation

2) I understand that my participation is voluntary and that I am free to withdraw at any time, without giving any reason and without my medical care or legal rights being affected. (Required)

Agreed to data/medical notes for research purposes

3) I understand that relevant sections of my medical notes and data collected may be looked at by the research team and individuals from the Sponsor (University of Edinburgh), NHS Lothian, or regulatory/other authorities, where it is relevant to my taking part in this research. I give permission for these individuals to have access to my records. (Required)

Confirmed personal information

4) I give permission for my personal information (including name, address, date of birth, telephone number, email address and consent form) to be passed to the University of Edinburgh for administration of the study. (Required)

Opt in for non-identifiable data for research usage

5) I agree to the use of my non-identifiable data in future research studies. (Required)

Opt in for non-identifiable data for research sharing

6) I agree to sharing of my non-identifiable data with other researchers for research purposes. (Required)

Confirmed commercial development

7) I understand that research projects may include commercial development of products, test, treatments or biomarkers and I understand I won’t benefit financially from this. (Required)

Confirmed research collaborations

8) I understand that some research collaborations may include groups outside of the UK where laws protecting personal information are different. I agree that my non-identifiable data can be shared with these researchers. (Required)

OPTIONAL PREFERENCES FOR LEVEL OF PARTICIPATION

YesNo

9) I agree to be contacted in the future regarding research studies that may be of interest to me. (Required)

YesNo

10) I agree to be contacted to assist in the design and implementation of future research projects. (Required)

YesNo

11) I agree to be contacted if there is a need for members of a focus/consultation group. (Required)

Your Name (Required)

Date of Birth (dd/mm/yyyy) (Required - we need this to help identify you)

Diagnosis (Required)

I don't have a diagnosisI don't know what my diagnosis isMultiple sclerosis (MS)Motor neurone disease ( MND / ALS )Parkinson's disease (PD)Dementia (any type)Other

Other:

Further MS Diagnosis

relapsing remitting (RRMS)primary progressive (PPMS)secondary progressive (SPMS)Other/I don't know

Other/I don't know

Address line 1 (Required)

Address line 2 (Required)

Postcode (Required)

Your Email (Required)

Don’t have an email address? No problem, you can still sign up to Rowling CARE. Please speak to a member of staff or call us on 0131 465 9517.

Your phone number

I prefer to be contacted by:

EmailPhone