Third Party Consent Form

Consent Form to allow Third-parties access to GP Health records

This form to be used when a patient would like to allow access to third parties ( including relatives , partners etc) to their GP health records.

DD slash MM slash YYYY
I allow permission to:

I consent for the aforementioned third party representative to have access to my confidential information from my GP medical record as stated in this form. If anything changes in relation to this third party consent, I (the patient) understand that it is my responsibility to inform the practice of this change.
DD slash MM slash YYYY
Does the patient consent to receive SMS/email alerts?
This form collects your name, date of birth, email, other personal information and details of third party you are submitting . This is to confirm you are registered with the practice, to allow the practice team to contact you. Please read our privacy policy to discover how we protect and manage your submitted data.