Thank you for supporting the work of the communications teams at UCLH. To enable us to share your story we need your permission. We want to ensure that you fully understand and consent to the way your story and personal data may be used. You also have the opportunity to withdraw your consent at any time.

Please indicate those uses of your personal data that you consent to:

UCLH writing up your story and/or taking your picture and/or video for use in (tick as appropriate):
Others (tick as appropriate):
Sharing your story and any accompanying images/video with other organisations UCLH works with:
Date of birth: Required


We will use your data as part of the work that University College London Hospitals NHS Foundation Trust does to raise awareness of disease prevention, detection and treatment, as well as research and clinical trials. You can withdraw your consent at any time by emailing

However, once your patient story has been shared externally, UCLH has no control over how or where the material is used. The material may still be accessible to people through websites, cached internet pages and social media sites beyond the control of UCLH.


  1. This form should be filled in by the participant.
  2. If the participant is under 18 years of age, a parent/guardian can complete it on their behalf.
  3. If a patient has given verbal consent but is unable to give written consent, this form can be filled in by the UCLH member of staff taking consent and annotated with their name and date until the patient is able to give written consent.
  4. This form should be saved in the patient’s medical notes and a copy sent to the Communications Team,