Third Party Consent to Allow Access to Medical Records

Please complete this form if you wish to grant a representative the ability to communicate with us about you.

This will enable them to gain information about you, and your medical problems, talk to us about your care and give and receive information about you. It will not entitle them to order copies of your medical records, sign consent on your behalf, withdraw care or sign an order to prevent your resuscitation.

Giving consent to someone else to communicate with us about you and your medical problems is a very significant step and you should give it serious consideration before you give consent.

You need to consider what they might learn about you and your problems that you did not want them to know, and have fully considered the ramifications of giving consent.

If you are unsure about giving consent, we advise that you do not give it and that you seek legal advice before proceeding.

YOUR DETAILS (Patient Allowing Third Party Access)

Forename

Surname

NHS Number (If Known) :

Email Address

Mobile Phone Number

Home Phone Number

Address with postcode

YOUR REPRESENTIVES DETAILS

Forename

Surname

Relationship to you

Email Address

Mobile Phone Number

Alternative Phone Number

Address with postcode

Please tick which of the following applies (or all if necessary)

Next of Kin
Emergency Contact
Consent to Discuss Medical Records

I consent to the release of confidential information from my medical record as stated in this form to the person(s) stated above.

Yes

I understand my representative’s information will be stored for future reference in the medical file The Practice holds in relation to me

Yes

I understand that I must check any correspondence sent to my email from The Practice.

Yes

If you need to clear your signature from the box above and start it again, click here.

Electronic Signature

Todays Date

Clark Avenue Surgery

Clark Avenue Surgery

Third Party Consent to Allow Access to Medical Records