{# decision_form_to_patient_re_study.html #} {% extends 'base_pdf.html' %} {% comment %} template parameters: contact_request: ContactRequest study: Study patient_lookup: PatientLookup settings: Django settings object extra_form: bool n_forms: int yellow: bool {% endcomment %} {% block content %}
Your clinician has asked you whether you’d like to be contacted about this study:
{% include "study_table.html" with study=study omit_id=True only %} {% include "phrase_never_affect.html" %}Would you like this research team to contact you?
Please tick one option, then sign and date the form.
( ) | 1. {% if extra_form %} Yes, please allow this research team to write to me. Please pass on the information requested by the researchers on the enclosed form, and allow them access to my full CPFT records. {% else %} Yes, please allow this research team to write to me, and allow them access to my full CPFT records. {% endif %} I understand that they will write to me about this study, but that there’s no commitment to take part. |
( ) | 2. No, do not pass on my details to this research team about this study, and do not allow them access to my full CPFT records. |
By signing you also agree that the CPFT Research Database Manager (who is independent of the research team) can see the information you send back, in order to record your choice, and pass on information to the researchers if that’s what you want.
{% endif %} {% include "signature_box_patient.html" with patient_lookup=patient_lookup %} {% if patient_lookup.is_under_15 %}As you are under 16, please also fill in the box on the next page.
{% elif patient_lookup.is_under_16 %} {# Might have been sent out with 16th birthday approaching, etc. #}If you are under 16, or another adult is making decisions on your behalf, please also fill in the relevant box on the next page.
{% else %}If another adult is making decisions on your behalf, please also fill in the box on the next page.
{% endif %}Please return {% if n_forms == 3 %} all forms {% elif n_forms == 2 %} both forms {% else %} this form {% endif %} to {{ settings.RDBM_ADDRESS|join:", " }}. Postage is free, and an envelope is enclosed. You can also give {% if n_forms == 2 %} the forms {% else %} this form {% endif %} to a member of staff at CPFT. If you would like more information from your health care professional before completing this form, please feel free to ask.
Thank you!