Sign Up On Behalf of A Patient

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

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

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

I confirm that I would like to provide consent to participation in Rowling CARE on behalf of an individual who lives in Scotland and has a neurological condition

I confirm that I would like to provide consent to participation in Rowling CARE on behalf of an individual who lives in Scotland and has a neurological condition. (Required)

This individual cannot provide consent himself/herself because of (Required)

Physical impairmentCognitive (thinking and/or memory) impairment

Your relationship with the participant – please choose one (Required)

I confirm that I am the nearest relative for the participant and that no other nearest relative or Welfare Attorney or Guardian existsI confirm that I am the Welfare Attorney or Guardian for the participant

Name of the person for whom consent is being provided (“the participant”): (Required)
[text]

Note –the term “relative” is used here to represent the person for whom you are considering consent. Consent can only be provided if you are the nearest relative, guardian, or welfare attorney.

Date of Birth of the participant for whom the consent is being provided (dd/mm/yyyy) (Required - we need this to help identify the participant)

Address of the participant for whom the consent is being provided

Address line 1 (Required)

Address line 2 (Required)

Postcode (Required)

Diagnosis of the participant for whom the consent is being provided (Required)

No diagnosisDiagnosis unknownMultiple 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

In the following questions, the participant will be referred to as your ‘relative’

I confirm that I have read and understood the 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)

I understand that my relative’s participation is voluntary and that I am free to withdraw my relative at any time without giving a reason and without their medical care being affected.

2) I understand that my relative’s participation is voluntary and that I am free to withdraw my relative at any time without giving a reason and without their medical care being affected. (Required)

I give permission for these individuals to have access to my relative’s records.

3) I understand that relevant sections of my relative’s 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 relative’s taking part in this research. I give permission for these individuals to have access to my relative’s records. (Required)

I give permission for my relative’s personal information to be passed to the University of Edinburgh for administration of the study.

4) I give permission for my relative’s 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)

I agree to the use of my relative’s non-identifiable data for research.

5) I agree to the use of my relative’s non-identifiable data for research. (Required)

I agree to the sharing of my relative’s non-identifiable data with other researchers for research purposes

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

OPTIONAL PREFERENCES FOR LEVEL OF PARTICIPATION

YesNo

7) I agree to my relative being-contacted in the future regarding other research studies that may be of interest. (Required)

Your Name (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