Third Party Consent

If you wish to register a third party for representation, please submit this form.

If you change your mind, please contact the practice.

Please be aware that any replies from the surgery may appear in your Junk Inbox.

Third Party Consent

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Patient Details

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 act on my behalf in relation to the healthcare I receive from Enderley Road Medical Centre and other third party health and social care providers that Enderley Road Medical Centre may have been made aware of. Such as referrals and results from hospitals.

I also fully consent to Enderley Road Medical Centre disclosing to the person named above any information including personal data held by Enderley Road Medical Centre in relation to the care received from Enderley Road Medical Centre and wider health and social care providers.

Please update my records accordingly. I will notify Enderley Road Medical Centre should I change my mind.

Signature: *

Date:

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Patient Details

Third Party

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