Third party consent

Third Party Consent

Patient Details

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Your First Names: *

Your Last Name: *

Your Phone Number: *

Your Email: *

Third Party

I hereby authorise:

Full name of third party: *

Relationship to you:

Phone number of third party:

Home Address (including postcode)

To discuss my care and medical records and act on my behalf in relation to the healthcare I receive from The Kenneth MacRae Medical Centre.

I also fully consent to The Kenneth MacRae Medical Centre disclosing to the person named above any information including personal data held by The Kenneth MacRae Medical Centre for the purpose of providing this service.

Please update my records accordingly. I will notify The Kenneth MacRae Medical Centre should I change my mind.

Signature: *

Date:

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Patient Details

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Third Party