Third Party Consent Form

Patient Details

Date of Birth

Third Party Consent for Authorised Representative

I hereby consent to my doctor releasing information to, and discussing my care and medical records with the person named below.
I give consent for this information to be shared for the next
Please be advised you can add or withdraw your consent about sharing information with your Next of Kin at any time.


Please note that no medical information or questions will be responded to. The data you supply on this form will be stored on our website, which is hosted by a third party, until it has been processed by the practice. The data will be used lawfully, in accordance with the Data Protection Act 2018, which gives you the right to know what information is held about you, and sets out rules to make sure that this information is handled properly. The practice privacy policy can be viewed on this website.
Full Name
This field is for validation purposes and should be left unchanged.