Consent to share information

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