Phoenix Health Group NHS GP Surgeries in Gloucestershire

Consent to discuss my health with someone else

Address:

NHS Number:

Usual GP:

About the person who will have access

Full name of person having access:

One name per form

Their relationship to patient:

e.g. Neighbour/Daughter/Friend

Their phone number:

Is this person also registered as a patient at Phoenix Health Group?

Yes

Would you also like them recording on file as your next of kin and/or emergency contact?

Yes

What can be shared with this person?

Please confirm what you would like to share with the person named above:

To be given test results and immunisations

To be able to discuss questions about my medication or prescription requests

To be able to ask details of my appointments – e.g., times and dates, to be able to cancel appointments and make appointments where necessary.

To be able to discuss any referrals that have been made on my behalf

Other

Please specify:

Your Consent

Patient’s Signature:

Full name

Date:

You can change your mind. Consent may be revoked by the patient at any time by putting this in writing to the practice.

Phoenix Cirencester
9 Chesterton Lane
Cirencester
GL7 1XG

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01285 652056

Phoenix South Cerney
Clarks Hay
South Cerney
Cirencester
GL7 5UA

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Phoenix Royal Agricultural University
Cirencester
Gloucestershire
GL7 6JS

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Phoenix Kemble
Church Road
Kemble
Cirencester
GL7 6AE

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Phoenix Tetbury
41-43 Long Street
Tetbury
Gloucestershire
GL8 8AA

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Consent to discuss my health with someone else

About the person who will have access

What can be shared with this person?

Your Consent