Use this form if you wish to grant a representative the ability to communicate with us about you and your health. To submit the form, the patient and the representative must attend the surgery and provide valid photo ID. If the patient lacks capacity to consent or is housebound please call the surgery to discuss this request.
Completing this form will enable the person(s) of choice to gain access to information about you and your medical problems, talk to us about your care, and give and receive information about you.