Group Consultations Confidentiality Form
Brompton Primary Care Network
Name (Please print clearly):
Date of Birth:
Daytime phone number:
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.
Your clinician (doctor, nurse or pharmacist) and other members of your healthcare team, if present, will be doing likewise. Staff are bound by their employment contracts and professional codes of ethics to respect patients’ confidentiality. Please read the statement below. By agreeing to attend the session, you are agreeing to the terms outlined below:
Statement of confidentiality
By attending a group consultation, 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. 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 or to schedule an individual practice 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 agreeing to 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. Consent will also be checked before the beginning of the session.
Date: Signed (carer/support person if applicable):
I CONSENT AS ABOVE IN ALL OF MY GROUP CONSULTATION SESSIONS RUN BY BROMPTON PRIMARY CARE NETWORK