Data Protection Declaration

This declaration should be signed by the patient, if over 18, or by a parent/guardian if the patient is a minor, or by a spouse, adult children or parents if the patient lacks the ability to make an informed decision.

ExtraLife Limited confirms that it will comply with the Data Protection Act 1998 in the management and retention of any information provided in this questionnaire ("Patient Data") and, in particular, shall:

1. Only process such Patient Data as is necessary to provide cardiological medical health care services;

2. Ensure that all Patient Data is kept securely and in accordance with the requirements of the Data Protection Act 1998;

3. Maintain all appropriate technical and organisational measures in place to guard against unauthorised or unlawful processing of Patient Data and against accidental loss, damage or destruction;

4. Take all reasonable steps to ensure the reliability of its staff who will have access to any Patient Data.

I understand that, in compliance with the Data Protection Act 1998, the information I have provided to ExtraLife Limited may be shared with hospitals and consultants and other medical professionals during the course of health care facilitation, unless I specify otherwise i.e. I may not wish for my medical records/Patient Data to be sent to a particular person or body.

Please do not send my medical records/Patient Data to:___________________

Signed: ________________________  Dated:_____________________