Patient consent form for another person to discuss your medical care

Your medical record is confidential, and staff at the Practice will not give out any information about your healthcare to other people without your consent. This includes information about your appointments, test results and medication.

If you would like a relative, spouse, friend or carer to be able to discuss any aspect of your care with staff, please complete this form.

Your details

Full name

Date of birth

Address

Home number

Mobile number

Details of person to be able to discuss your care

If more than one person is to be given permission, then please list the below details for each additional person

Full name

Date of birth

Address

Home number

Mobile number

Relationship to you

Is the above person your next of kin?

Yes

Please say below if you want to limit the information that we pass on (e.g. only for test results, or only for making & cancelling appointments, or for a specified time period only)

I confirm that I give permission for staff at Combe Down Surgery to discuss my medical care with the person named above.

Signature

Write your full name to sign the form

Date