Enrolment Form

I consent to Ashdale Care Ltd accessing all relevant information relating to my care provided in Ashdale and I accept that this may contain medical/clinical information about me/my relative.

I understand that information relating to me may be held electronically and that all personal data will be dealt with according to relevant Data Protection legislation and Ashdale’s General Data Protection Policy.

Information relating to me will be held in accordance with recommended legislative guidelines. I understand that Ashdale Care Ltd and its representatives employed by Ashdale Care Ltd, may need to contact and share with external third parties as necessary.

I have read and understood Ashdale’s General Data protection statement above

Yes No

I understand that I can ask questions about the policy and procedures to the Management of Ashdale Care Home.

Yes No

I understand that I can withdraw from the consent form at any time and I do not have to give any reasons why I no longer want to take part

Yes No

I understand my personal/medical details, will be shared with relevant parties and am happy to consent to this.

Yes No

I agree for the data I provide to be archived by Ashdale Care Ltd in line with our regulations and inspection guidance/minimum standards provided by the Care Inspectorate for Wales and am happy to consent to this.

Yes no

I understand that other authenticated employees will have access to this data only if they agree to preserve the confidentiality of the information and am happy to consent to this.

Yes No

Name of resident/representative:

1. I have been involved with the development of my care plan

Yes No

2. I understand that I can access my records at anytime

Yes No

3. I understand that my records may be shared with other health and social care professionals who are involved in my care

Yes No

4. I authorise health and social care professionals involved in my care to discuss my needs with the care home staff

Yes No

5. I agree to photographs of me being used in my personal records

Yes No

6. I consent to the treatment and personal care detailed in my care plan

Yes No

6. I consent to the treatment and personal care detailed in mu care plan

Yes No

If you would like a relative or advocate to be involved in your care, please provide their details below:

Relationship to you:

Name of resident/representative:

These are my hopes and wishes regarding my future care and treatment should I become unable to make those decisions for myself.

I am aware that this is not a legally binding document.

If I lose the capacity to make decisions, I wish for this document to be used by others regarding my treatment and care.

Medication