ࡱ> ,.+7 bjbjUU .$7|7| l  j$$$$$$$$$j  $$$$$$$$ $$$3$ Ъ .K0 S,. DL. PATIENT CONSENT TO VIDEO RECORDING Date ................................................................................... Patients name ................................................................................... Name(s) of person(s) accompanying patient ................................................................................... Dr ..............................................................................., whom you are seeing today, is hoping to make video recordings of some consultations. The reasons for making a video are to help the doctor with his or her consulting skills. The spotlight will be on the doctor not on you. The video is ONLY of you and the doctor talking together. Intimate examinations will not be recorded and the camera will be switched off at any time if you wish. All video recordings are carried out according to guidelines issued by the General Medical Council. It will only be used to assess the doctor whom you are consulting, and possibly for research, learning and teaching purposes and quality control. The tape will be securely stored and is subject to the same degree of confidentiality as your medical records. The tape will be erased as soon as practicable and in any event within three years. The security and confidentiality of the video recording are the responsibility of the doctor. You do not have to agree to your consultation with the doctor being recorded. If you do not want your consultation to be recorded, please tell Reception. This is not a problem, and will not affect your consultation in any way. But if you do not mind your consultation being recorded, we are grateful to you. If you wish, you may view the tape recording before confirming your consent. If you consent to this consultation being recorded, please sign where shown below. Thank you very much for your help. TO BE COMPLETED BY THE PATIENT I have read and understood the above information and give my permission for my consultation to be video recorded. Signature of the patient BEFORE THE CONSULTATION ................................................................................... Date ................................................................................... Signature(s) of any person(s) accompanying the patient ................................................................................... Date ................................................................................... After seeing the doctor I am still willing / I no longer wish my consultation to be used for the above purposes. Signature of patient AFTER THE CONSULTATION ................................................................................... Date ................................................................................... Signature(s) of any person(s) accompanying the patient ................................................................................... Date ................................................................................... $fQ CJOJQJaJCJ 5CJ\&+dfT Q p  i n O T G & Fdd[$\$$a$- $]^a$$a$,1h. A!"#$%  i8@8 NormalCJ_HaJmH sH tH <A@< Default Paragraph FontJ^`J Normal (Web)dd[$\$CJOJQJaJ $&+dfTQpinO T  G - 00000000 0 0 0 0 000000000000000000000 0 i 3##RT  Julie DraperrC:\Dumbflea\JULIE\Assessment and appraisal\PATIENT CONSENT TO VIDEO RECORDING edited from the MRCG model 2004P.docV(h^`CJOJQJo(^`CJOJQJo(opp^p`CJOJQJo(@ @ ^@ `CJOJQJo(^`CJOJQJo(^`CJOJQJo(^`CJOJQJo(^`CJOJQJo(PP^P`CJOJQJo(V(tl |[!V-{4K *^@  $    @@UnknownGz Times New Roman5Symbol3& z Arial7&  Verdana?5 z Courier New;Wingdings"hԁځ !20 2Q%PATIENT CONSENT TO VIDEO RECORDING Julie Draper Julie DraperOh+'0 ,8 T ` lx&PATIENT CONSENT TO VIDEO RECORDING t ATI Julie DraperNT uliuliNormalr Julie DraperNT 1liMicrosoft Word 9.0V@@&@4X ՜.+,0  hp|  N  &PATIENT CONSENT TO VIDEO RECORDING Title  !"$%&'()*-Root Entry Fs /1TableWordDocument.$SummaryInformation(DocumentSummaryInformation8#CompObjjObjectPools s   FMicrosoft Word Document MSWordDocWord.Document.89q