Third Party Consent Form

Your medical record is confidential, and staff at the Practice will not give out any information about your healthcare to other people without your consent. This includes information about your appointments, test results and medication. If you would like a relative, friend or carer to be able to discuss any aspect of your care with staff, please complete the below online form.

Your Details

Name(Required)

First Last

Date of Birth(Required)

Phone(Required)

Email(Required)

Address(Required)

Street Address Address Line 2 City County Post Code

Details of the person to be able to discuss your care

Name(Required)

First Last

Phone(Required)

Relationship to you(Required)

Is this person your next of kin(Required)

[Note: Next-of-kin is a person’s closest living blood relative or relatives. In cases of medical emergency, where a person is incapable (either legally because of age or mental infirmity, or because they are unconscious) of making decisions for themselves and they have no spouse or children, medical decisions can be made by the next-of-kin in preference to the wishes of medical personnel.

Yes

Do you want to limit the information that we pass on (e.g. only for test results, or only for making & cancelling appointments, or for a specified time period only)