Third Party Consent Form

If you would like a nominated person to act on your behalf, please complete this form.

Please note that one of our Medical Secretaries will contact you to verify the signed consent form.

If you are human, leave this field blank.

Section

I hereby give consent for the nominated person (details below) to:

Be given any test results on my behalf

To collect medications on my behalf

Discuss my health with a GP/Secretary/Receptionist

To be told that I need an appointment and to be able to book for me

To receive any correspondence sent by the practice

Please be aware that any correspondence sent from the practice will go to the address of the nominated person below and you will no longer receive any correspondence from us.

Nominated Persons' Details

Full Name: *

Date of Birth: *

Please use the format: DD/MM/YYYY.

Home and/or Mobile Number: *

Relationship to Patient: *

Address (including postcode): *

Signature of Patient: *

Date:

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