The Beacon Medical Centre

01395 512601

Third Party Consent Form.

Please let us know if you would like another person to be able to speak on your behalf regarding your medical information.
This could be to book or cancel an appointment, discuss blood test results or general information regarding your medical record.

Third Party Consent Form

  • Patient Details

  • Date Format: MM slash DD slash YYYY
  • Third Party Consent for Authorised Representative

    I hereby consent to my doctor releasing information to, and discussing my care and medical records with the person named below.
    Please be advised you can add or withdraw your consent about sharing information with your Next of Kin at any time.
  • Date Format: DD slash MM slash YYYY