Third party consent

What is your name?

First name

Last name

What is your date of birth?

For example, 31 3 1980

Day

Month

Year

What is your sex?

As recorded on your medical record

Male

Female

Other

What is your postcode?

The one used to register with your GP

What is your phone number?

What is your email address?

Anyone else with access to your email account may see responses sent to you

Address: Required

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

Full Name: Required

Address: Required

Are there other individuals that require access? Required

Yes

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: Required

Date:

Please specify: Required

Patient

Parent

Guardian

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

Section

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: