Brief clinical details: (please attach recent letter or discharge summary)
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Consent:
*please delete as appropriate
| I have been provided with the patient information leaflet which explains the role of the National CJD Surveillance Unit and the National Prion Clinic. |
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| I agree to my/the patient's* details being forwarded to the National CJD Surveillance Unit and the National Prion Clinic. |
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| I agree that staff from the National CJD Surveillance Unit in Edinburgh and the National Prion Clinic in London can visit myself/the patient* and my/their* relatives at a mutually convenient time for clinical assessment and surveillance purposes and to provide the opportunity, should we wish, to discuss ongoing research, including clinical trials of potential treatments. |
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| I understand that this may mean providing further information to help in the organisation of my/the patient's* care, and to contribute to a better understanding of the illness. |
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Signed: .............................................................................................................
Print: ..................................................................................................................
Date: .................................................................................................................
On completion, please fax to NCJDSU 0131 343 1404, NPC 0203 448 4046
and also to your local CCDC
