Consent Form For Access To Care Records
FORM UHS-F0166
Care Service
Location of Office
Please Select
Cleethorpes
London
Name of person using the service whose consent is being sought
*
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Service User Address
*
Street Address
Street Address Line 2
City
County
Postcode
Decision Date
-
Day
-
Month
Year
Date
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Choice
What is the choice being made?
GP Connect (consenting to allow their NHS GP Connect record to be accessed via CareLineLive)
Other (any other choice that the client has made)
Decision
Has the client accepted the choice?
Accepted?
Decision comments
*
Authourised by
Who authorised the choice?
*
Self (the service user has made the choice themselves)
Next of Kin (the client's next of kin has made the choice on their behalf)
Power of Attorney (the client's power of attorney has made the choice on their behalf
Other
Optionally include additional information about who authorised the choice.
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Supported by
Was the service user supported in making this choice?
Yes
No
Supported by whom?
First Name
Last Name
Signature of person using the service
or Signature of service user representative
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Continue
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Should be Empty: