Consent To Release Confidential Medical Information To A Third Party
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1FOR OFFICE USE
PATIENT NO:
CONSENT TO RELEASE CONFIDENTIAL
MEDICAL INFORMATION
TO A THIRD PARTY
I
Of
D.o.B.:
Telephone:
give my consent to the release of confidential information from my medical records as follows:
Please give the name and address of
the person or organisation you wish the
information to be given to:
Please describe what information
you want released:
(e.g. details concerning headaches, all
hospital letters, my physiotherapy reports,
etc)
Please indicate if you wish to see the
I DO NOT WISH TO SEE
report before it is sent or not:
I WISH TO SEE
I understand that this consent is enduring, unless I give written notification otherwise.
Signed:
Date:
Please return this form to the University Health Service
Dr Sarah J R Armstrong
Dr Suzy C Bannister
Dr Mark Edwards
Dr Christopher J James
Dr Heather N Wilson
Practice Manager: Mrs. Wendy Fielder
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Parent category: Business