Please complete this form if you wish to give a representative permission to communicate with us about you.

What this consent allows

This consent will allow your representative to:

  • receive information about you and your medical problems
  • speak to us about your care
  • give information to us about you
  • receive information from us about you

What this consent does not allow

This consent does not give your representative permission to:

  • order copies of your medical records
  • sign consent on your behalf
  • withdraw care on your behalf
  • sign an order to prevent your resuscitation

Please think carefully before giving consent

Giving consent for someone else to communicate with us about you and your medical problems is a very significant step.

You should give this serious consideration before you provide consent.

Please think about what your representative may learn about you or your medical problems, including information you may not have wanted them to know.

If you are unsure

If you are unsure about giving consent, we advise that you do not give it at this stage.

You may wish to seek legal advice before proceeding.

YOUR DETAILS (Patient Allowing Third Party Access)

YOUR REPRESENTIVES DETAILS