Prostate Cancer Support Group
Kidderminster and District

Registered Charity No 1100718                                                    P.O. Box 3854
Web site                                                                                  Kidderminster
www.kidderminsterpcsg.com                                                 Worcs., DY11 5WP

 What is the purpose of this form?   The Prostate Cancer Support Group of Kidderminster & District would like to start a 'buddying' system for members of the group.  For the committee to administer this we need the participation of members who are willing to become ‘buddies’ to new members.  If you chose to participate in this scheme you are required to sign this form, so that health information may be stored, so that it will be possible to match up new patients with ‘buddies’. The information will be stored on a data base, which will be only be accessible to the Clinical Nurse Specialist who is a member of the Committee and members of the Urology Teams at Kidderminster Hospital and Mr. Baxter-Smith (Consultant Urologist) at Droitwich Spa Hospital.  The information stored will be strictly confidential.

Why do you need my health information?  Health professionals will need to be able to use your health information to appropriately match you with another prostate cancer patient who is potentially considering the same treatment that you have had, and who can benefit from the knowledge of someone who has completed their journey.

Who will disclose, use and/or receive my health information?  No health information will be disclosed or shared under any circumstances.  The medical and nursing staff who can access the Buddy database are the only people who will know your health information.  The only personal information disclosed to other patients, is your contact details which you supply to us and are happy for us to share with other individuals e.g. e-mail; telephone number, address.  This will permit other patients to contact you.  The choice will be yours whether to just submit e-mail contact or telephone contact details, and whether you wish to withhold your address.

How will my health information be protected once I disclose it to the Buddy Database?   Your health information that is given remains private and confidential under the laws of Data Protection Act (1998) and the policies and procedures within the Worcestershire Acute NHS Trust.

Can I withdraw from the Buddy Database?  You can withdraw from the Buddy Database at any time by notifying Mary Symons on 01562 512328/01299 823166

or e-mail:- Mary.Symons@worcsacute.nhs.uk or mandmsymons@talktalk.net
If you withdraw, all information will no longer be used and safely removed from the database.

I agree that my personal health information can be stored and used on the Buddy Database for the Prostate Cancer Support Group of Kidderminster& District, to allow healthcare professionals to match me up to another Cancer patient.

Please tick the box    o

I agree to share my preferred method of contact details with another prostate patient(s) through this network.
Please tick the box     o

If you have any questions/concerns please contact the Support Co-ordinator

Mary Symons 01562 512328/01299823166

or e-mail Mary.Symons@worcsacute.nhs.uk or mandmsymons@talktalk.net

Prostate Cancer Support Group
Kidderminster and District

Registered Charity No.1100718                                                            P.O. Box 3854
Web site:- www.kidderminsterpcsg.com                                               Kidderminster,
                                                                                                              Worcs., DY11 5WP

BUDDY DATABASE

Personal details

PLEASE PRINT IN BLOCK CAPITALS

First name:

Surname:

Date of birth:

Address 1

Address 2

Address 3

Post code:

Telephone (home):

Mobile telephone:

E-mail:

Please tick the appropriate box in each of the three sections

Preferred method of communication

Letter        o
E-mail        o                             
Telephone       o
One-to-one (face to face)                   o     

Details of cancer journey.

Diagnosis:              

Localised                                       o
Locally advanced                            o
Metastatic                                      o     

Treatment:                                                            
Radical prostatectomy                     o
Laparoscopic prostatectomy             o
Hormone manipulation                     o
Subcapsular Orchidectomy                o
Radical radiotherapy                        o
Brachytherapy                                 o
Active surveillance                           o
Watchful waiting                             o
Other treatment                              o                  please give details

Please let us know if you are willing to take patients to another centre for treatment, e.g. Wolverhampton for Radiotherapy.   Initially for the first visit, to help ease them into the system. 
The group will refund any fuel costs.