Patient Consent Form

Please complete this form if you wish to give someone else consent to view your medical records.

Patient Consent Form

Patient Consent Form

Patient's Details

Please use date format DD/MM/YYYY
All responses will be sent to this email address.

Details of person to be given access

Please tick the appropriate: *
I can confirm that I give permission for the practice to communicate with the person identified above.
You can revoke this access at any point - please inform reception if you no longer want someone to have access to your behalf.

Consent for children under 16 (Gillick Competence)

Everyone aged over 16 is presumed to be competent to give consent for themselves, unless the opposite is demonstrated.
If a child under the age of 16 has “sufficient understanding and intelligence to enable him/her to understand fully what is proposed” (known as Gillick Competence), then s/he will be competent to give consent for him/herself.
Young people aged 16 and 17, and legally ‘competent’ younger children, may therefore sign this Consent Form for themselves, but may wish a parent to countersign as well which can be done below.
If the child is not able to give consent for him/herself, someone with parental responsibility should do so on his/her behalf by signing this form below.
I am the: