Care Information Exchange sign-up form https://www.chelwest.nhs.uk/about-us/care-information-exchange-sign-up-form https://www.chelwest.nhs.uk/++resource++plone-logo.svg Care Information Exchange sign-up form User email: Please leave this blank!!! The CIE gives you access to parts of your health record such as blood test and X-ray results. Please note: Only patients with an NHS number can sign up for this service After you complete this form, we will arrange a call to confirm your identity—please ensure you have a government-issued photo ID available, such as a driving licence or passport About you First name Surname Email address NHS number Date of birth Postcode If you have an existing CIE account, please specify how you signed up I don't have a CIE account I signed up at a check-in kiosk I signed up in another way (please specify) Other: I am under the care of maternity services About your carer Would you like a carer (friend/family) to have access to your health record on your behalf? Yes No If 'yes', please complete the rest of this section. If 'no', please skip to the next section. Carer’s first name Carer’s surname Carer’s email address Consent I consent to my clinicians having access to the following categories of my health record: General health: Most of your health record is general health and includes information that most health professionals will use to deliver care Social care: Information about the care you receive from your local authority social care team, including disability funding—this is very useful in helping to manage home care services Mental health: Information about mental health conditions, such as diagnoses of anxiety, depression or schizophrenia—it is very useful for your GP to see such information alongside your mental health team Sexual health: Information about sexual health, including reproductive health and HIV We recommend that you select all categories. I consent to my carer accessing the following categories of my health record: General health Social care Mental health Sexual health Complete this only if you have a carer. Improving our services I am happy to be contacted by the CIE team in future to give feedback to improve our services Submit Contributors George Vasilopoulos
