EMBRACE-Diabetes Practice Pro Forma

EMBRACE-Diabetes

Practice Pro Forma

ECLIPSE, in collaboration with AstraZeneca, is conducting a risk-based case-finding, triage, and treatment optimisation programme, for your patients with Type 2 Diabetes aged 18 years or over.

Please complete the pro forma below to provide practice consent for this service.

Practice Name:

National Practice Code

Programme Activation

AZ EMBRACE – Diabetes

Contacting Patients

1. Are you happy for patients within the activated cohort to be contacted by the ECLIPSE automated patient engagement interface? (NB: this will involve SMS messaging).

Yes

No

2. Are you happy for patients within the activated cohorts to be contacted by a patient engagement team? (NB: this will involve telephone calls):

Yes

No

3. Are you happy for patients to receive a feedback questionnaire for evaluation of the programme and to allow them to express any personal preferences:

Yes

No

Key Contacts

Practice Admin Lead:

First Name

Last Name

Email

Practice Clinical lead:

First Name

Last Name

Email

EMBRACE-Diabetes

Eclipse Partnership Programme