GDPR Consent Form Name * First Name Last Name Date of Birth * MM DD YYYY Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Mobile Number * Country (###) ### #### GP Details * THIS IS A CONSENT FORM FOR SHARING INFORMATION WITH PEOPLE OR ORGANISATIONS NOT DIRECTLY INVOLVED WITH YOUR TREATMENT AT HARLEY STREET PSYCHIATRY. During your care at Harley Street Psychiatry, we want to make sure we fulfil all your expectations for confidentiality in accordance with the General Data Protection Regulations (GDPR). Your clinical and personal information is held confidentially. We would like to know who we can contact and share information: GP INFORMATION SHARING * I consent for relevant clinical information to be shared with my GP: Yes No OTHER INFORMATION SHARING I consent to the following relatives/external professionals being contacted for the purposes of sharing information about my treatment: Name First Name Last Name Relationship to you Contact information Name First Name Last Name Relationship to you Contact information All data processed by Harley Street Psychiatry is in accordance with GDPR 2018. You will be attending Harley Street Psychiatry premises for consultations and treatment and are aware that non-medical details (name, age, address and date of birth) will be recorded on a database for administrative and accounting purposes. Information will not be shared with third parties without consent unless requested by a Court, to safeguard adults/children at serious risk of harm, or to protect the public. Harley Street Psychiatry works in partnership with a range of professionals depending on the nature of your treatment. If we need to share information with professional colleagues involved with your treatment we will seek your consent in advance. Your signature below confirms your agreement to the contents in this form. Confirm your acceptance of the above terms * I accept Thank you!