Request for third party to access a medical record

Use this service to give consent to a third party representative to access your medical record.

This form will confirm our ability to discuss information from a patient’s medical record with a third party representative. Unless otherwise specified, this consent will last for 12 months (at which point the patient needs to submit a further consent form to outline their continued consent).

You can use this service if you:

• are registered at the surgery

Before you start

We’ll ask you for:

• your first and last name, date of birth, sex, postcode, email and phone number
• if applicable, the details of the person you are completing the form on behalf of

Start now

You can also phone us on Burton Road 01332 737777 or Humbleton Drive 01332 737777.