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Consent for third parties to access medical records

Consent for Third Parties to Access Medical Records

Patient Details

Section

Are you submitting this on behalf of a patient? *
Are they aware you are submitting this on their behalf? *

We will always contact the patient to confirm their wishes with regards to third party consent.

Next of Kin

Third Party Details

The patient has given the following people access to either all or part of their medical record:

Consent

Please select all that you would like to give access to:

Please note that this request will remain on your record until you notify us to remove it. If any of the above information changes, please notify the practice.

It is your responsibility to inform the practice with immediate effect if your consent changes.

*
E.g. Monday AM/PM, Tuesday AM/PM
Please upload any relevant evidence in relation to this form.
Maximum upload size: 67.11MB