Virtual Diabetes Group Consultation Signup

Please complete this form if you have received an invitation to attend a Virtual Diabetes Group Consultation. There are Frequently Asked Questions (FAQs) relating to virtual diabetes consultations; please review these to learn more and confirm you are happy to take part.

A confidentiality agreement needs to be completed before the session by all patients attending. Please complete this below and then await further information on the surgery with the log-in details for the session. Note: you may be called ahead of the session to have up-to-date blood tests and foot checks if these have not been done recently.

Group Consultations Confidentiality Form

Introduction to this Confidentiality Agreement

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. This applies equally if attending a group consultation in person or virtually, using a secure video and/or audio link to both the main session and any microconsults. Your clinician (doctor, nurse or pharmacist) and other members of your healthcare team including students, if present, will be doing likewise. Staff & students are bound by their employment/educational contracts and professional codes of ethics to respect patients’ confidentiality. Please read the statement below, and if you agree, please sign the form where indicated.

Statement of confidentiality

By signing this agreement, I undertake to respect the confidentiality of the other members of the Group Consultation by not revealing any medical, personal, or other identifying information about others in attendance, after the session is over. If I am attending virtually, I undertake to make sure that others cannot hear or see the group consultation, unless they are my carer who has also signed this form and that it is not recorded by anyone. My own information, however, belongs to me, and I understand that I am encouraged to discuss my own details with my carer or other family members, as appropriate.

I understand that if I have health concerns that are of a very sensitive nature, I may of course, ask to discuss them with the relevant staff member in a private treatment room, opt for a 1:1 discussion at the end of the session in person or virtually, or to schedule an individual appointment.

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

By signing this confidentiality form however, I am agreeing to share any relevant test results within my group.

At any time, I can withdraw my consent to this.

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Patient Details

Please use date format DD/MM/YYYY