Third Party Consent

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 Date of Birth:

Third Party

I hereby authorise:
Home Address (including postcode)
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.