Little Havens General Consent Form

Child/Young person's name*

First Last

Parent/Carers Email*

Date of birth*

NHS number

I give consent for my child to participate in:

Please tick all that you give consent to, leave blank the options you do not give consent for.

I give consent for my child to have photographs taken and used for:

Care Records
Therapeutic activities/artwork
Pictorial memories (to be handed back to the family)
Media (if you are happy for us to share your child’s photos publicly, we’ll speak to you about a separate Consent for Publicity Form)
I am happy for group photographs to be shared amongst the other patients/children featured
Updating parent / carer of activities and events during stays sent via WhatsApp

Please tick all that you give consent to, leave blank the options you do not give consent for.

I give my consent for my child's information to be use for

Internal clinical audit (The audit process is completely anonymous and is used to monitor and inform standards of care)

Please leave blank if you do not give your consent

Parent/carer full name - this will be used as your electronic signature*

Consent*

I agree that my full name in the field above will be used as my electronic signature

Date*

Little Havens Consent Form