Breathe Melodies for Mums Registration Form SHAPER

Breathe Melodies for Mums Registration Form

Thank you for your interest in the Breathe Melodies for Mums Programme.

We are currently delivering this programme as part of a research project and as such by completing and submitting this form you are consenting to us sharing your details with the research team.

Completing this form is the first step in expressing your interest to attend a Breathe Melodies for Mums Programme. Once completed, you should expect to hear from one of our team within three weeks. They will be able to provide guidance around the next steps in signing up to attend the programme as well as answer any questions you may have.

If you require any help completing this form or would like to receive it in a different format please contact us by email on m4m@breatheahr.org or telephone 07511 214 069.

We look forward to hearing from you!

Fields marked with * are mandatory.

 

Personal Details

*Mother’s Full Name:

*Mother’s Date of Birth:

*Baby’s Full Name:

*Baby’s Date of Birth (Please note to be eligible for this programme your baby must be aged 9 months or younger at the start of the programme):

*Baby’s Gender:

*Email:

*Telephone:

*Street:
*City:
*Postcode:
*Country:

*Emergency Contact Full Name:

*Emergency Contact Number:

*GP’s Name:

*GP Practice:
*City:
*Postcode:
*Country:

*GP’s Contact Number:

*Recruitment Method: (select from dropdown)

Other, Please Specify:

Please complete this form after you have read the Information Sheet.

Title of Study: SHAPER-PNDO

In order for us to then contact you if you are potentially eligible for our study, we would like to ask you to read this consent form.

Your information I may be subject to review by responsible individuals from the research team for screening, monitoring and audit purposes.

Confidentiality will be maintained and you will not be identified in any research outputs.

Please read the statements below and tick “yes” or “no”.

I consent to the processing of my personal information for the purposes of being contacted for the study. I understand that such information will be handled in accordance with the terms of the General Data Protection Regulation.




I consent to my contact details being retained so that I may be invited to re-screen in the future, should I not be eligible to enrol in the study at this time based on my screening answers.




I consent to my GP being contacted if there are any concerns for my or my baby’s wellbeing.




 

By submitting this form you are consenting to our privacy policy.

Please note: We are currently delivering a research study in South East London. By submitting this form you are consenting to the Breathe Team sharing any information with the research team as well as the agreement outlined in Patient Information Sheet and Consent Form provided by the research team.

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