Consent form for medical care to be discussed with another person (Proxy)

Use this service to give consent for medical care to be discussed with another person.

Once it is submitted, a member of our team will call the patient to arrange a telephone consultation with their GP to complete the authorisation process.

You can use this service if you:

• are registered at the surgery

Before you start

We’ll ask you for:

• your first and last name, date of birth, sex, postcode, email and phone number
• if applicable, the details of the person you are completing the form on behalf of

Start now

You can also phone us on Brookside Surgery 0118 966 9333 or Chalfont Surgery or Winnersh Surgery or Wilderness Road Surgery .