Consent Form For Medical Care To Be Discussed With Another Person

We require a consent form to be in place for medical care to be discussed with another person, therefore please complete and submit this form.

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.

Consent Form For Medical Care To Be Discussed With Another Person

Consent Form For Medical Care To Be Discussed With Another Person

Patient Details

Please use this date format: DD/MM/YYYY.
This is the email we can contact you with.

Representative's Details

Please use this date format: DD/MM/YYYY.
This email cannot match the same as the Patient Details

Telephone Consent

Care to be Discussed:
Please select at least one
Duration: *
Please add duration 'until' date.

Online Access

Please note - If the representative does not have an online account with us, they must request this first; please ask at reception for more information.

I agree that my representative can access my medical record to:
Duration: *
Please add duration 'until' date.