Third Party Consent to Access Medical Records

Please complete this form if another person other than the patient is required to access their medical records.

If you are human, leave this field blank.

Patient Details

First Name: *

Surname: *

Sex: *

Male

Female

Indeterminate

Address (including postcode): *

Telephone Number: *

Details of person to be given access to information

Full Name: *

Address (including postcode): *

Telephone Number: *

Does another person require access? *

Yes

Details of person to be given access to information

Full Name: *

Address (including postcode): *

Telephone Number: *

Email Address:

Detail below if the above access is to be limited in any way (e.g. only for test results, or only for making and cancelling appointments, or for a specified time period only):

I confirm that I give permission for the practice to communicate with the person identified above in regards to my medical records:

Signature: *

Date:

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Third Party Consent to Access Medical Records

Patient Details

Details of person to be given access to information

Details of person to be given access to information

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