Date/time of Details of Patient Full Name Date of Birth NHS Number Address Tel. No. Description of Image I consent to the attached images being supplied to NHS Dudley for processing my application for treatment. Signed:________________________________ Date:______________________ If under 16 years old consent of parent/guardian is also required Signed:________________________________ Date:______________________ NHS Dudley may store supplied image and the information supplied on this form, you have a right to see a copy of the information held about you on application to the Associate Director of Governance. The Trust’s Associate Director of Governance can be contacted on 01384 322050 or via Email at . Further information relating to the Data Protection Act 1998 can be found on the Information Commissioner’s website at Disclaimer: All patient identifiable information, including data held electronically, clinical records, photographs and audio tapes will be stored in line with the Trust Records Management Policy. Furthermore, patient information will not be held for longer than is necessary, and will be ultimately destroyed in a confidential manner in line with our Trust Retention Schedule. A copy of the Trust Health Records Policy and the Trust Retention and Disposal Policy can be found Appendix 2 Breast Augmentation Guidelines If the patient meets with the breast augmentation criteria, the following information will be required by the NHS Dudley Exceptional Treatment Approval Panel in order to reach a fully informed and fair decision about the individual patient request.
Date/time of Details of Patient Full Name Date of Birth NHS Number Address Tel. No. Description of Image I consent to the attached images being supplied to NHS Dudley for processing my application for treatment. Signed:________________________________ Date:______________________ If under 16 years old consent of parent/guardian is also required Signed:________________________________ Date:______________________ NHS Dudley may store supplied image and the information supplied on this form, you have a right to see a copy of the information held about you on application to the Associate Director of Governance. The Trust’s Associate Director of Governance can be contacted on 01384 322050 or via Email at . Further information relating to the Data Protection Act 1998 can be found on the Information Commissioner’s website at Disclaimer: All patient identifiable information, including data held electronically, clinical records, photographs and audio tapes will be stored in line with the Trust Records Management Policy. Furthermore, patient information will not be held for longer than is necessary, and will be ultimately destroyed in a confidential manner in line with our Trust Retention Schedule. A copy of the Trust Health Records Policy and the Trust Retention and Disposal Policy can be found Appendix 2 Breast Augmentation Guidelines If the patient meets with the breast augmentation criteria, the following information will be required by the NHS Dudley Exceptional Treatment Approval Panel in order to reach a fully informed and fair decision about the individual patient request.
Aesthetic%20Surgery%20Guidelines%20&%20Commissioning%20Policy%20-%20Oct%202010.docx