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Healthy Cornwall

Easy Read self referral form

Questions marked with * need to be filled in
Your name Your name *
Are you male or female? Are you male or female? *

Do you have a disability? Do you have a disability? *
Do you have a learning disability? Do you have a learning disability? 
Do you have an annual health check at your GP surgery? *<br /><br />You can get your health checked every year. This is from when you are 14 years old. This is to make sure that you stay healthy. Do you have an annual health check at your GP surgery? *

You can get your health checked every year. This is from when you are 14 years old. This is to make sure that you stay healthy.
 

Do you have a physical disability? Do you have a physical disability? 
Do you need information in a special way? Like large print or Easy read Do you need information in a special way? Like large print or Easy read 
What are your communication needs? What are your communication needs? 
Where do your live? Where do your live? *
What date were you born? What date were you born? *
Have you had your free health check at your GP Surgery? *<br /><br />This is your chance to get your health checked. This is from when you are 45 years old. This is to make sure that you stay healthy. Have you had your free health check at your GP Surgery? *

This is your chance to get your health checked. This is from when you are 45 years old. This is to make sure that you stay healthy.
 

What is your phone number? What is your phone number? 
What is your email address? What is your email address? 
Where is your GP Surgery Where is your GP Surgery *
What support do you need? Tick which ones you would like help with

What support do you need? Tick which ones you would like help with

 
 
How did you hear about Health Promotion Service? How did you hear about Health Promotion Service? 
Are you pregnant? Are you pregnant? 
Consent to contact me and to keep my personal information

Consent to contact me and to keep my personal information

It is OK for you to contact me It is OK for you to contact me *
What is the best way to contact you?

What is the best way to contact you?

By phone By phone 
By email By email 
By letter By letter 
It is OK for you to contact my GP It is OK for you to contact my GP *
More information

More information

Anything else we need to know about you? Anything else we need to know about you? 
<h2>Statement of consent</h2><br /><br />Statement of consent means this is a record of your consent

Statement of consent



Statement of consent means this is a record of your consent
Please read carefully

Please read carefully

If you need help to read and understand please ask.

If you need help to read and understand please ask.

I <strong>agree</strong> that the information I give Healthy Cornwall will be kept in a safe way. It will only be seen by staff who are helping me.

I agree that the information I give Healthy Cornwall will be kept in a safe way. It will only be seen by staff who are helping me.

I <strong>understand</strong> that my information may be shared with other health and social care staff. This is to make sure I get the best support.

I understand that my information may be shared with other health and social care staff. This is to make sure I get the best support.

If there is a concern about your safety or that of others your personal information has to be shared.

If there is a concern about your safety or that of others your personal information has to be shared.

I <strong>understand</strong> that the information will be used for the purpose of giving a service.

I understand that the information will be used for the purpose of giving a service.

I understand that anonymised information may be used for research.

I understand that anonymised information may be used for research.

<strong>Anonymised information</strong> means that none of your personal information is showing. This may be your name and date of birth.

Anonymised information means that none of your personal information is showing. This may be your name and date of birth.

I <strong>understand</strong> that at any time I can say that I do not want my personal information to be shared.

I understand that at any time I can say that I do not want my personal information to be shared.

This may limit the support we can offer you.

This may limit the support we can offer you.

I <strong>understand</strong> that I can ask for some of my personal information not to be shared.

I understand that I can ask for some of my personal information not to be shared.

This may limit the support we can offer you.

This may limit the support we can offer you.

I <strong>understand</strong> that my information will be held safely on paper and or on a computer.

I understand that my information will be held safely on paper and or on a computer.

We will use the Data Protection Act 2018 to look after it correctly.

We will use the Data Protection Act 2018 to look after it correctly.

If you do not want your information to be shared with a person or organisation please let us know here: If you do not want your information to be shared with a person or organisation please let us know here: 
I confirm that I have read the above statement and consent to it. I confirm that I have read the above statement and consent to it. *