Consent form for medical care to be discussed with another person

Patient Details

Patient’s First Name:

Patient’s Surname:

Date of Birth:

Please use this date format: DD/MM/YYYY.

Email Address:

This is the email we can contact you with.

NHS Number (if known):

Full Name:

Date of Birth:

Please use this date format: DD/MM/YYYY.

Telephone Number: Required

NHS Number (if known):

Relationship to Patient:

Email Address: Required

This email cannot match the same as the Patient Details

Confirmation

I am unable to ring the surgery for my appointments, medications and medical results and wish to designate a representative to do so on my behalf

Confirmation

I am happy for my representative (who is a patient at the practice) to have ‘proxy access’ to my medical information online.