Sign Up On Behalf of A Patient

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

Rowling CARE Proxy Patient Information Leaflet V3.0 12th Nov 2018

Please see our privacy statement for more details of how we use the information we collection 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
Address of the participant for whom the consent is being provided

No diagnosisDiagnosis unknownMultiple sclerosis (MS)Motor neurone disease ( MND / ALS )Parkinson's disease (PD)Dementia (any type)Other

relapsing remitting (RRMS)primary progressive (PPMS)secondary progressive (SPMS)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.
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.
Opt in for non-identifiable data for research
Opt in for sharing non-identifiable data with 3rd parties
Opt in to storage of contact details/future contact for other studies
Opt in for contact in design/implementation of future projects