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Veterans Consent Form

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Veterans Mental Health Service

If you need help completing this form, please call our service

Consent to Release Service and Medical Information

I give permission for the Veterans’ Mental Health TIL Service (TILS) and Complex Treatment Service (CTS) to verify my military service with the MOD and if necessary to request copies of my service and/or medical records (e.g. from DCMH, PRU and/or DMS).*
I give permission for my medical records from my General Practitioner (GP) to be provided to the TILS & CTS.*
I understand that I have the right to withdraw my consent at any time by:
  • Speaking to staff at the TILS or CTS
  • Letter (4th Floor, West Wing, St Pancras Hospital, 4 St Pancras Way, London, NW1 0PE)
  • Phone (0203 317 6818)
  • Email (cim-tr.veteranstilservice-lse@nhs.net)
*
I give permission for my information to be used anonymously for research and service evaluation purposes.*
I give permission for my information to be shared with my General Practitioner (GP).
We are unable to proceed with your referral if you do not consent for us to share information with your GP*

Information shared with the services indicated above shall be: the minimum necessary; in compliance with both the Data Protection Act (2018) and the General Data Protection Regulation (GDPR, 2016); and accessed only by appropriate staff on a need to know basis.