Patient Consent

Use this form to inform us another person can discuss/access your medical records.

Patient Consent

If you are human, leave this field blank.

Full Name: *

Relationship to patient:

Address: *

Please include postcode

Telephone Number:

I give the person named above permission to be given instructions relating to my medical care, for example blood results and medication changes.

I understand that the doctor may override this authority at any time, and that this permission will remain in force until cancelled by me in writing.

In addition the named person may be linked to my records.

Signature: *

Enter full name of patient

Date:

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