Consent Form

The Consent for Approach for Research Database is for patients who have kidney disease and are being cared for by a hospital kidney team.

You can fill this form in for yourself, or on behalf of a relative/friend if they are over 16 and unable to physically do so themselves. As much of the research will require answering questionnaires, your relative/friend must however have ‘capacity’. Capacity is the ability to understand information and make their own decisions. They must be able to verbally communicate answers to you for you to complete this form and any subsequent questionnaires on their behalf.

I am filling this form:

If you are completing this form with someone else, please read these statements to them:

I confirm that I have kidney disease being managed by a hospital kidney team.
I give my permission for the database team to confirm this with my hospital if needed.
I have read and understood the Patient Information Sheet.
I agree that the UK Kidney Association may combine any information I provide with other information they already have about me, as explained in the Patient Information Sheet.
I understand that my participation is voluntary and that I am free to withdraw at any time without giving any reason.
I provide my consent to participate.

I confirm the person I am completing this form for has capacity:

Date of birth of patient:

First name:

Last name:

NHS number: Please enter a 10-digit NHS number

Patient's main hospital and/or satellite unit:

Enter hospital, if other:

Postcode of patients home address:

Contact email: Please enter a contact email

Contact Options

We can send information and survey links via email or by a text message to a smartphone. A smartphone usually has a touch screen and has can be used to access the internet.

If you prefer to be contacted by text, please enter a valid mobile phone number below

Send me SMS notifications:

Contact phone: Please enter a UK phone number

Link that opens policies

I confirm that I/the participant has understood the content of the relevant information sheet and is happy to give their consent to participate:

Submit Consent