Bleed kit registration form

Organisation/Company Name

Address line 1*

Address line 2

Town*

Region

Postcode

Country

Availability (specific days/hours or 24/7)*

Entry location – (eg on the right hand side of the main door)*

Keycode (if applicable)

Guardian's contact details:

Contact Name (Guardian)*

Phone number*

Email Address 1*

Earliest expiry date in the bleed-kit*

I consent to having my submitted information processed by this website, so the Trust can respond to request. I understand that this information is stored in a secure internal database by the Trust.*

As a protection against spam, please type the letters and/ or numbers you see:*

The Data Protection Act 2018
As an NHS Trust we will not disclose your personal details to third parties without your explicit permission, unless there are exceptional circumstances such as; when it is in the public interest to investigate a serious crime, or to prevent serious risks to the public or NHS staff; or to protect children or vulnerable adults or where the law requires information to be shared through a formal court order. If the Trust does have to pass on any of your personal information to a third party it will follow the guidance and application of the Data Protection Act 2018. The Legal Basis for processing your personal data is with your explicit consent. You have the right to withdraw your consent at any point by informing the Community Collaboration Team at the above address and or the Data Protection Officer informationgovernance@eastamb.nhs.uk.