Consent to share information

Section

Carer/relative details

Name

Relationship to patient

Address

Postcode

Phone number

Email address

I give permission for my Carer / Relative(s) to have access to my medical records and personal details held by Cutlers Hill Surgery, Halesworth and for staff to discuss this with my Carer / Relative(s).

This permission relates to

All of my records

Part of my records

Where permission is restricted to part of my records, the only areas to be included are:

Allow Appointment Booking

Allow Medication Requesting

Allow Completing Questionnaires

Allow Viewing of Summary Care Record

Allow Coded or Full Record

I understand that this consent will remain indefinitely, however, my doctor may at my request withdraw this authority to my medical records.

Patient’s signature

Enter full name

Date

I will treat any information provided confidentially. I will not disclose information to a third party without agreement and will only use the information in the best interests of the person I care for.

Carer/relative’s signature

Enter full name

Date

Do you need to add additional carers/relatives?

Yes

No

Carer/relative details – 2

Name

Relationship to patient

Address

Postcode

Phone number

Email address

I will treat any information provided confidentially. I will not disclose information to a third party without agreement and will only use the information in the best interests of the person I care for.

Carer/relative’s signature – 2

Enter full name

Date

Carer/relative details – 3

Name

Relationship to patient

Address

Postcode

Phone number

Email address

I will treat any information provided confidentially. I will not disclose information to a third party without agreement and will only use the information in the best interests of the person I care for.

Carer/relative’s signature – 3

Enter full name

Date

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Section

Carer/relative details

Carer/relative details – 2

Carer/relative details – 3