By filling in this form you confirm that the patient has freely chosen to authorise Coloplast Limited t/a Coloplast Charter to supply the patient with their prescription items. Please remember to provide a copy of this form to the patient. You warrant that the patient has expressly agreed that Coloplast Charter may hold and store their personal information including sensitive health information for administration purposes and to process orders and that Coloplast Charter may share this with Healthcare Professionals and others where necessary to deliver the products or as required by Law. The patient has been informed that they may withdraw consent for data processing at any time without ramifications, by writing to privacyrequests@coloplast.com or calling Coloplast Charter at 0800 132 787. You also confirm that you have advised the patient to visit Charter’s privacy policy at www.coloplastcharter.co.uk/cookies-and-privacy-policy/ for further information.