Patient Consent Form

Please complete this form if you wish to give someone else consent to view your medical records.

If you are human, leave this field blank.

Patient's Details

Full Name: *

Contact Number:

Address including postcode: *

Details of person to be given access

Full Name: *

Relationship to patient: *

Contact Number:

Email Address: *

Address including postcode: *

Please tick the appropriate: *

I would like to above person to have temporary access and collect my results as a one off.

I would like the above person to be able to collect my results and have access to my medical record, medication/prescriptions, and appointments and give permission for them to speak to a health care professional on my behalf.

Please create a secret word that your nominated person will be asked to quote: *

Please detail below if the above access is to be limited in any way (e.g. only test results, or only making and cancelling appointments)

I can confirm that I give permission for the practice to communicate with the person identified above.

Signature: *

Date:

You can revoke this access at any point - please inform reception if you no longer want someone to have access to your behalf.

Consent for children under 16 (Gillick Competence)

Everyone aged over 16 is presumed to be competent to give consent for themselves, unless the opposite is demonstrated.

If a child under the age of 16 has “sufficient understanding and intelligence to enable him/her to understand fully what is proposed” (known as Gillick Competence), then s/he will be competent to give consent for him/herself.

Young people aged 16 and 17, and legally ‘competent’ younger children, may therefore sign this Consent Form for themselves, but may wish a parent to countersign as well which can be done below.

If the child is not able to give consent for him/herself, someone with parental responsibility should do so on his/her behalf by signing this form below.

I am the:

Patient

Parent

Guardian

Signature:

Full Name:

Address (if not the same as patient):

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