Release of Medical Information to Relative/Carer Consent Form

Your details

Full Name

Date of Birth

Address & Postcode

Mobile Phone

Details of the person you give consent to

I hereby consent to the release of my medical information for the purpose of my further medical care to the below person.

Full Name

Address & Postcode

Home Phone (if different)

Mobile Phone (if different)

Relationship

Are you register with this practice?
Yes No

Consent

I declare that the information provided on this form is correct to the best of my knowledge

Yes

I consent to being contacted via the details given above. I agree to the privacy policy

Yes

To view our privacy policy, click here

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Millennium Medical Centre

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