Consent to Share Information

If you are happy to give consent to share your information with a carer or relative, we will be happy to add a note to your medical record. Please complete our Consent to Share Information form.

Consent to share information

If you are human, leave this field blank.

Patient Details

Full Name: *

Date of Birth: *

Address: *

Post Code: *

Telephone Number:

Email Address: *

Carer/Relative Details

Full Name: *

Telephone Number:

Address: *

Post Code: *

Relationship to Patient: *

Email Address: *

I give permission for my relative/carer to have access to my medical records and personal details held by the Practice and for staff to discuss this with my relative/carer.

This permission relates to: *

All of my records

Parts of my records

Where permission is restricted to part of my record, only the areas included are: *

Specific exclusions are:

I understand that this consent will remain in force indefinitely. However, my Practice may, at my request, override this authority to allow access to my medical records at any time.

I will treat any information provided confidentially. I will not disclose information to a third party without agreement and will only use the information in the person that I care for’s best interest.

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Patient Details

Carer/Relative Details

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