Permission to Discuss my Health & Records with Someone Else

Dr Alice Pater
Dr Ros Phillips
Dr Jayne Adams
Dr Vanithamani Sundararajan
The Surgery
Templars Way
Sharnbrook
BEDFORD
MK44 1PZ
Permission to Discuss my Health & Records with Someone Else
Please complete this form if you wish to grant a representative the ability to communicate with us about you and your health.

Completing this form will enable the person(s) of choice to gain access to information about you and your medical problems, talk to us about your care, and give and receive information aboutyou.

Giving consent to and for someone else to communicate with us about you and your medical problems is a very significant step and you should give it serious consideration. You need to consider what they might learn about you and your health, that you did not or may not want them to know.

By completing this form, you are advising that you have fully considered the ramifications of giving that consent. If you are unsure about giving consent, we advise that you do not give it and that you seek legal advice before processing.
About me (the patient):
Patient's Full Name

First NameLast Name
Patient's date of birth:

DayMonthYear
Patient's NHS Number (if known):
Patient's contact telephone number:
About them (the person who will now have access):
The name of the person I am giving access to:
Their relationship to me: (e.g. Spouse/Son/Daughter/Neighbour/Friend)
Is this person also registered as a patient at Sharnbrook Surgery themselves?
Their telephone number(s):
Would you also like them recording on file as your next of kin and/or emergency contact?
What can be shared with this person - please select box(es):

Other (please specify)
Signed and authorised by me, the patient:
Patient's Signature:
Date:

DayMonthYear
You can change your mind!

Consent may be revoked by the patient at any time, by writing to the Practice Manager.

This extra section only applies if a patient is not capable to consent:

If a patient is incapable of giving consent, this form can be signed (above) on their behalf by someone else, providing that this representative has a legal "Lasting Power of Attorney (LPA) for Health and Care Decisions" or other legal document confirming this authority and leave a copy of such legal document with the form (please never leave original copies).
Full name, address and phone number of representative who has signed this on behalf of the patient.
Patient representative full name:

First NameLast Name
Date of birth:

DayMonthYear
Address:

Street Address Line 2

CityState / Province

Postal / Zip Code
Contact Number
If you are unable to provide this documentation, please speak with the Practice Manager.
Should be Empty:

Permission to Discuss my Health & Records with Someone Else

About me (the patient):

About them (the person who will now have access):