Third Party Consent - Drayton Medical Practice

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

Please read the form below carefully and submit once complete.

About you

Your First Name(s):

Your 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