Consent form to collect items and documents on behalf of a patient’

If you would like another person (s) to collect prescriptions or document from the surgery on your behalf, we need to gain your consent.

Please complete the form below to apply for another person to be granted permission to collect prescriptions / documents on your behalf.

Once approved, we will apply a note to your clinical record indicating your consent.

Name of patient

Date of Birth

I consent to the following person (s) collecting the below on my behalf (please tick as appropriate)

Please add the name (s) and relationship (s) of elected individuals

Name

Relationship

Signature of patient

Todays Date

If you wish to change these instructions, please contact the practice