Third Party Consent

If you wish to register a third party for representation, please submit this form.

If you change your mind, please contact the practice.

Third Party Consent

Patient Details

Third Party

I hereby authorise:
To discuss my care and medical records and act on my behalf in relation to the healthcare I receive from Drayton Medical Practice.

I also fully consent to Drayton Medical Practice disclosing to the person named above any information including personal data held by Drayton Medical Practice for the purpose of providing this service.

Please update my records accordingly. I will notify Drayton Medical Practice should I change my mind.