Consent Form

Consent Form

First Name *

Last Name *

Address *

Email *

Enter Email

Confirm Email *

Confirm Email

Date of birth *

Please use format day/month/year e.g. 12/05/1979

Telephone Number *

Details of person to be given access to information

First Name *

Last Name *

Please enter a date on which their temporary access will expire. If left blank this will be considered to be granting of permanent access.

Consent is to be given for them to access

Please tick to accept in the boxes below.

Full Medical Access

Appointments Only

Prescriptions / medication

Results

Referrals / correspondence

Your Consent

Please tick to accept in the boxes below.

I confirm that I give permission for the Practice to communicate with the person identified above in regards to my medical records.

Privacy Policy

This form collects your name, date of birth, email and other personal information. This is to confirm you are registered with the practice, to allow the practice team to contact you and also to update your medical records held by the practice and our partners in the NHS. Please read our Privacy Policy to discover how we protect and manage your submitted data.

I consent to the practice collecting and storing my data from this form.

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Details of person to be given access to information

Consent is to be given for them to access

Your Consent

Privacy Policy

Summerfield Health Centre

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