Third party consent

Section

Address: *

Details of person(s) to be given access to this patient’s information

Full Name: *

Address: *

Are there other individuals that require access? *

Yes

No

Full name:

Address:

Full name:

Address:

Please specify if the access is to be limited in any way (e.g. only for test results, or only for making and cancelling appointments, or for a specified time period only):

Consent for children under 16 (Gillick Competence)

Everyone aged 16 or more is presumed to be competent to give consent for themselves, unless the opposite is demonstrated.

If a child under the age of 16 has ‘sufficient understanding and intelligence to enable him/her to understand fully what is proposed’ (known as Gillick Competence), then they will be competent to give consent for him/herself.

Young people aged 16 and 17, and legally ‘competent’ younger children, may therefore sign this consent form for themselves, but may wish a parent to countersign as well.

If the child is not able to give consent for themselves, someone with parental responsibility should do so on their behalf by signing this form.

I confirm that I give permission for the practice to communicate with the person(s) identified above in regards to my medical records:

Signature: *

Date:

Please specify: *

Patient

Parent

Guardian

Do you want to counter sign this form? *

Yes

No

Counter signature: *

Date:

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Section

Details of person(s) to be given access to this patient’s information

Consent for children under 16 (Gillick Competence)

I confirm that I give permission for the practice to communicate with the person(s) identified above in regards to my medical records: