Sign Up On Behalf of A Patient

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

Address of the participant for whom the consent is being provided

Further MS Diagnosis

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’

Confirmed voluntary participation

I confirm that I have read and understood the information sheet (dated 8th August 2017, version 2.0) 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.

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)

Opt in for non-identifiable data for research

I understand that relevant sections of my relative's medical notes and data collected during the study 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 taking part in this research. I give permission for these individuals to have access to my relative’s records. (Required)

Opt in for sharing non-identifiable data with 3rd parties

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

Opt in to storage of contact details/future contact for other studies

I agree to the sharing of my relative’s non-identifiable data with third parties for research (this means that we can share your relative’s data with our research collaborators and partners, but only with their name, date of birth and address removed).

Opt in for contact in design/implementation of future projects

I agree to the storage of my relative’s contact details and re-contact in the future regarding other research studies that may be of interest.

Your Name (Required)

Your Email

Your phone number