Third Party Consent - Drayton Medical Practice

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About you

First Name(s):

Last Name:

Postcode:

Your Date of Birth:

Gender

Your Phone Number:

Your Email:

Third Party

I hereby authorise:

Full name of third party:

Relationship to you:

Phone number of third party:

Home Address (including postcode)

Street Address Address Line 2 City Postcode

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

Signature:

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.

Date