Consent for another person to access your medical records

If you wish for someone else (i.e a relative) to be able to discuss your medical records, including being given access to your test results & appointment information you will need to complete a consent form for this. If you are under 16 years old the consent form will only apply until the age of 16 when a new form would need to be completed. If you are over 18 and choose to complete the consent to allow access to medical records form this consent will remain active indefinitely unless stated otherwise or you take action to rescind the consent given.

Last Updated: 13/05/2021

Patient Details

FULL NAME *

date of birth *

address *

Contact Number *

Details of person/people to whom you give consent to access the above patients information

Person Number 1 Full name *

address *

Relationship to patient ie: mother, son etc *

Second person's full name ( if applicable)

Address

Relationship to patient

Level of access granted

Please detail below if the above access is to be limited in any way (eg 'only for test results' or 'only for 3 months from today') If no information is given in this section full access will be granted to your record, including on-line access if requested.

Consent

For patients aged under 16 years of age - I understand that the consent given now will last until my 18th birthday (unless I rescind it prior to this date myself) and after that date, should I still wish to grant consent, another form will need to be completed. I confirm that i give permission for the Practice to communicate with the person/people identified above in relation to my medical records

FULL name *

Date *

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Consent for another person to access your medical records

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