Consent to share information

Section

Disclosure options

Please tick the statement/s applicable:

Full and open ended disclosure of all matters related to my medical record

Full disclosure of all matters related to my medical record for a specific period

Limited disclosure of specific aspects of my medical record

Other matters related to my medical record

Please state the specific period:

From:

DD/MM/YYYY

To:

DD/MM/YYYY

Limited disclosure of the following aspects of my medical record:

Test results

Prescription queries

Referral queries

Any other matter related to my medical record, please state:

Please note: If you are between the ages of 11 and 15, it will be your responsibility to notify the surgery to update this consent when you turn 16, if necessary.

Consent withdrawal:

I am aware that this consent may be revoked by me at any time.

Confidentiality agreement:

I will treat any information provided confidentially. I will not disclose information to a third party without agreement and I will only use the information in the best interest of the person I care for.

Signature:

Please enter your full name

Date:

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Section

Disclosure options

Please state the specific period: