1. Introduction 

As a participant in Group Consultations, both you and the other patients who are sharing the appointment will discuss medical information in the presence of other patients, and also staff. Your clinician and other members of your healthcare team will also do so. 

Staff are required to respect patients’ confidentiality. Staff would only share things with other people (including the GPs or the wider General practice team) if you ask them to, or if the safety of you or someone else were at risk.

Statement of confidentiality  

By signing this agreement, I agree to respect the confidentiality of all parties involved by not sharing any medical, personal, or other information identifying others in attendance, after the session is over. 

I understand that if I have health concerns that are of a very sensitive nature, I may ask to discuss them privately at the end of the session or to schedule an individual appointment. 

I understand that I am under no responsibility to share personal information with other patients, or healthcare staff, unless I choose to do so. 

2. Statement of consent for participating in the evaluation of the programme

I agree to take part in the evaluation of the impact of the Perinatal Community Support Programme. I understand that data collected during the programme and its evaluation will be looked at by clinicians & staff from working in the Optivita pilot including the Sphere and Collaborative Primary Care Networks (PCN), Imperial College London and Royal Holloway and Bedford New College. 

I give permission for these persons to have access to my records and collect data, including my and my child’s subsequent use of NHS services over the next year. 

I understand that information collected about me will not identify me and I will not be identified in any presentations or publications.

I give permission to be contacted by individuals evaluating the programme over the next year, as per date on this form.

3. Consent

By signing below, I confirm I have read and agree to this confidentiality and consent form, and understand that: 

• My contact details and any information I have provided will be held in accordance with the UK General Data Protection Regulation and the Data Protection Act 2018;
• I can withdraw my consent at any time by sending an email to optivita@blossomantenatal.com, but I am aware it will not be possible to remove my data from any published material created prior to my instruction.