Patient Consent

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

Patient Consent

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Details of person to be given access to this Patient’s information

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

Signature: *

Enter full name of patient

Date:

Important -

If you have any questions regarding the closure of Toftwood Medical Centre please follow the link provided where you will find relevant information: "Toftwood residents to be ... Find out more

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Details of person to be given access to this Patient’s information

Signature

Care Quality Commission