Consent form to allow another person to discuss and access your medical records

If you would like another person (s) to speak to us about our health needs, medication, test results or any other matter, we need to gain your consent.

Please complete the form below to apply for another person to be granted permission to discuss your medical records with us.

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

About You

Name of patient

Date of Birth

I consent to the practice (please select as appropriate)

Speaking to those named below about my health needs
Speaking to those named below about my medication
Speaking to those named below about my test results
Speaking to those names below about the following specific information (please add clear instructions)

List specific information

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

Name

Relationship

If you need to clear your signature from the box above and start it again, click here.

Signature of patient

Todays Date

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