Third Party Consent Form

If you require another person to discuss information on behalf of you, please submit this form.

If you are a parent or guardian, please indicate on the form and sign on the patient’s behalf.

Please note, you will need to provide ID and we will contact you to confirm consent.

Third Party Consent

If you are human, leave this field blank.

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

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

Counter signature: *

Date:

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Third Party Consent Form