Consent to discuss my health with someone else

Address:

NHS Number:

Usual GP:

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

No

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

Yes

No

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:

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.

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