Patient consent

Full Name:

Address:

Please include postcode

Telephone Number:

Relationship to patient:

If more than one person is to be given access, please complete one form for each person.

Please 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

Confirmation

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

Signature:

Enter full name

Date:

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