Consent for third parties to access medical records

Patient Details

Section

Are you submitting this on behalf of a patient? *

Yes

No

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

Yes

No

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

Address: *

Next of Kin

Full Name:

Relationship:

Contact Number:

Third Party Details

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

Full Name: *

Relationship: *

Contact Number: *

Address: *

Full Name:

Relationship:

Contact Number:

Address:

Consent

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

Access to all

Results

Prescriptions

Appointments

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.

*

I confirm that I allow the above named people to have access to my record as outlined in this request

If we need to contact you to discuss anything related to your form when is the best time to contact you? *

E.g. Monday AM/PM, Tuesday AM/PM

Signature: *

Date:

Please upload any relevant evidence in relation to this form.