Patient consent form for another person to discuss your medical care

Your medical record is confidential, and staff at the Practice will not give out any information about your healthcare to other people without your consent. This includes information about your appointments, test results and medication.

If you would like a relative, spouse, friend or carer to be able to discuss any aspect of your care with staff, please complete this form. 

Your details

Details of person to be able to discuss your care

If more than one person is to be given permission, then please list the below details for each additional person

Is the above person your next of kin?
Write your full name to sign the form