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
Name*
First Last
Date of Birth*
DD slash MM slash YYYY
Address*
Street Address Address Line 2 City ZIP / Postal Code
Telephone Number*
Email*
Enter Email Confirm Email
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.
Name*
First Last
Relationship to patient.*
Address
Street Address Address Line 2 City/town County Post code Country
Telephone*
I give consent for this information to be shared for the next
- 3 months
- 6 months
- 12 months
- Indefinitely.
Please be advised you can add or withdraw your consent about sharing information with your Next of Kin at any time.
Consent*
I agree the information provided is accurate and that I am the patient completing this form.
Consent*
I agree to the privacy policy.
Please note that no medical information or questions will be responded to. The data you supply on this form will be stored on our website, which is hosted by a third party, until it has been processed by the practice. The data will be used lawfully, in accordance with the Data Protection Act 2018, which gives you the right to know what information is held about you, and sets out rules to make sure that this information is handled properly. The practice privacy policy can be viewed on this website.
Signature*
Date*
DD slash MM slash YYYY

Third Party Consent Form

Patient Details

Third Party Consent for Authorised Representative

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Further Info