The TIMES Study – Telephone Patient Engagement Practice Pro forma

The TIMES Study
– Telephone Patient Engagement

Practice Pro-Forma

Please complete the pro forma below to provide your practice permission for the Eclipse patient engagement team to undertake telephone calls with your eligible patients to gather their expressions of interest.

As your practice already has a DPA (Data Processing Agreement) with Eclipse in place, our CQC accredited patient engagement team can carry out telephone calls to your patients on behalf of the practice to explain the programme and complete their Expression of Interests (EoIs) over the phone.

Given the nature of the eligible patients involved in this study (either coded with dementia or mild cognitive impairment), this method of patient engagement can be more effective for patient uptake than texts and will assist your practice in recruiting the required number of participants for this study.

We are here to assist and minimise workload for the practice and to ensure that the study is a success.

If you have any concerns, then please don’t hesitate to email or call the Eclipse Support Team at 07732215660 or email catherine.green@prescribingservices.org and nicola.finch-kerr@prescribingservices.org

Name of individual completing the form:

First Name

Last Name

Position:

NHS Email

Name of your GP Surgery:

National Practice Code: (optional)

Practice Admin Lead:

First Name

Last Name

NHS Email:

Programme Name:
The TIMES Study

1. Do you give permission for patients within the defined cohort to be contacted by the Eclipse patient engagement team (NB: this will involve telephone calls):

Yes

No

The TIMES Study– Telephone Patient Engagement

Practice Pro-Forma

The TIMES Study
– Telephone Patient Engagement