Medical Information Release Consent

Your rights

Only you or your personal representative has the right to access your medical information. To authorise a personal representative to be able to receive information from your medical records you must complete the consent form below authorising us to share this information.

Allowing access to your medical information

Please complete the consent form below to allow us to release your medical information to your nominated representative.

Consent form to allow your GP to release medical information

Please specify title

First name

Middle name

Last name

Date of birth

Primary phone

Mobile phone

Email address

Details of nominated representative that you authorise medical information will be shared with

Name

Phone

Relationship to you

Information to be released

Test results Medication information

If you have any restrictions, please note them

Please indicate if there is a specific timeframe to share your medical information with the above

Privacy Policy

Please note that we will not respond to any medical information or questions received through the form. Please note, unless a specific time frame is stated on this form, this medical release will remain in place on your records until consent is formally withdrawn in writing.

The information you supply us will be used lawfully, in accordance with GDPR Regulations. GDPR gives you the right to know what information is held about you, and sets out rules to make sure that this information is handled properly.

Please note that by using this form you will be sending information about yourself across the Internet. Whilst every effort is made to keep this information secure, you should be aware that we cannot offer any guarantees of absolute privacy. If this matter concerns you then you should use another method of registration.

Personal information retained on this system is stored in a secure data centre located in the UK and is treated as confidential.

Please read our Privacy Policy to discover how we protect and manage your submitted data.

Consent

I certify that the information I have provided is correct and consent to my personal information being used as stated above.

Signature (print name)

Date