Guidance

Appendix 1: consent form (accessible)

Updated 27 March 2025

UNITED KINGDOM Pre Entry Health Assessment for UK-bound Individuals on various Resettlement Schemes

Name

Date of birth

Clinic location

Applicant’s Declaration

I understand that:

• I am giving my consent to undergo a health assessment, which involves an interview, a physical examination, a chest X-Ray and blood and urine tests.
• The interview will involve questions about my physical and mental health, healthcare use, medication and psychosocial development.
• Physical examination will be guided by the clinician’s clinical judgement, and may include the measurement of blood pressure, body temperature, height and weight, and review of different systems and functions. Physical examination will include the assessment of mobility and ability to perform daily tasks independently.
• The blood test is a routine part of the assessment, and will include HIV, Hepatitis B, Hepatitis C and blood cell count, among other tests. Other tests such as urine testing may be recommended by the clinic.
• The chest X-Ray is part of the tuberculosis assessment, which has a separate consent form.
• Depending on the results of this assessment, I might be recommended to undergo further medical examinations, possibly by other doctors (for example a psychiatrist), to undergo treatment and/or receive vaccination prior to my entry in the UK.
• For immigration purposes I am required to undergo tuberculosis screening and, if necessary, treatment. Other requirements may be added to this list depending on international and national developments.
• Prior to departure I am required to undergo pre-departure medical procedures to establish my fitness to travel and, if necessary, receive treatment to ensure that I can travel safely and with special travel arrangements if I need any. I may also receive testing for and treatment against parasites.
• If needed, I will receive individual counselling and an explanation of further testing procedures.
• I have the right to refuse to undergo the health assessment procedure, treatment and vaccination, or to refuse part of the assessment. I do not need to explain my refusal, but am aware that refusal of tuberculosis screening and/or treatment may affect my application for transfer to the UK. I also understand that my refusal to undergo fitness to travel assessment may affect my transfer to the UK.
• I have the right to withdraw from the health assessment at any time, without having to give any reason.
• The results of this health assessment, including my personal information, health records and test results, will be shared with necessary UK authorities and agencies. Routinely this means the organisation processing my application, organisations providing accommodation or supporting my resettlement, and the organisation that oversees migrant health for the UK Government. The results will also be shared with UK health authorities at the point at which I register with a general practitioner (UK community doctor). I am advised to do this upon arrival in the UK. I understand that some conditions of public health concern are required by law to be reported to the national health authorities in the country of health assessment. Except for these purposes, my information will be kept confidential and only shared if there is a legal need or justification. My information may be shared for research or surveillance purposes – my personal identity will be protected in such cases, in accordance with UK requirements.

Female applicants

• I will be asked about my last menstrual period and may be asked to undergo a pregnancy test. Pregnancy does not exclude me from resettlement, but may alter the timing of when I am advised to travel.
• If I am pregnant, I acknowledge that a chest X-Ray, certain treatments and the minority of vaccines can carry a risk for an unborn child. I am therefore advised to consult the clinician and may wish to consult my gynaecologist to understand the risks before I undergo any of these procedures. If I decide to undergo these procedures, this shall be at my own risk.
• If I am pregnant, I will be offered alternatives to the procedures that carry a risk for me and/or for the unborn child.
• If I am pregnant I will be referred for routine antenatal care before arrival in the UK. Travel may be delayed in late pregnancy on advice of the clinician. My pregnancy will be risk-assessed, and if I would benefit from additional care this will be facilitated.

I hereby:

• Consent to undergo the health assessment
• Authorise you and your designated laboratory to store all relevant personal information collected during the assessment process
• Authorise you and your designated clinics to share my personal details and assessment results with the necessary UK authorities
• Authorise you to share my assessment results with the health authorities of the country in which the assessment is taking place, if this is required by the country’s laws, such as for notifiable diseases
• Release and hold harmless the UK Government and you from any liability for loss, injury suffered or other harm during, or as a result of, the health assessment procedure, except where such damage, claim and liability are caused directly by gross negligence or misconduct of the assessment service or relevant authority, its employees, medical personnel or its representative(s).

I have read this consent form, or had it translated for me. I was invited to ask questions to clarify what was not clear to me. I understand the content of this declaration.

Applicant’s signature / Date / Please print your name

…………………………………………………………………………………………………………………

For children, or adults without the mental capacity to give consent, I confirm that I am the parent or legal guardian of the applicant and confirm that I give my consent

For adults who are not able to physically sign the form, I confirm that I am an independent witness and the applicant has given their consent orally or by other non-verbal means

For minors below the age of consent without a parent or legal guardian, I am an accompanying adult

Signature / Date / Please print your name / Relationship to applicant

…………………………………………………………………………………………………………………

Statement of interpreter (if required); I have translated the content of this document for the applicant to the best of my ability and in a way in which I believe s/he can understand.

Signed / Date / Please print your name

…………………………………………………………………………………………………………………

For female applicants who might be pregnant; I confirm that I have had the risks of having a chest X-ray, certain treatments and vaccinations in pregnancy explained to me and I wish to carry on with these.

Signed / Date / Please print your name

…………………………………………………………………………………………………………………

While I agree with the health assessment in general, I wish to opt-out of the following part (s) of the assessment or associated tests and treatment:

…………………………………………………………………………………………………………………

Signed / Date / Please print your name

…………………………………………………………………………………………………………………

Statement of Clinician (if required); I have explained the content of this document to the applicant and confirm that the applicant has declined to go ahead with the assessment.

Signed / Date / Please print your name

…………………………………………………………………………………………………………………