Cardinal Medical Practice NHS GP Surgeries in Ipswich

Patient consent form for sharing medical information

Section

Relative/friend’s details (who you are giving consent to)

First name:

Surname:

Date of birth:

For example, 31/3/1980

Address:

Home number:

Mobile number:

Work number:

Email address:

Relationship to Patient:

I hereby give consent for the above person details to be recorded on my medical record and for them to have access to my medical records and/or discuss my medical requirements.

Please tick the statement to confirm you consent.

Full and open-ended disclosure of any matter related to my medical record.

Signature

Enter full name

Date

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Patient consent form for sharing medical information

Section

Relative/friend’s details (who you are giving consent to)