Please complete this form if you wish to grant a representative the ability to communicate with us about you.
This will enable them to gain information about you, and your medical problems, talk to us about your care and give and receive information about you. It will not entitle them to order copies of your medical records, sign consent on your behalf, withdraw care or sign an order to prevent your resuscitation.
Giving consent to someone else to communicate with us about you and your medical problems is a very significant step and you should give it serious consideration before you give consent. You need to consider what they might learn about you and your problems that you did not want them to know, and have fully considered the ramifications of giving consent.
If you are unsure about giving consent, we advise that you do not give it and that you seek legal advice before proceeding.
You may receive a telephone call to confirm this access request from a member of our administrative staff; this is to ensure any requests are made with the knowledge of the individual.
Access can be denied by the surgery should a member of the clinical team feel this request has not been made with the patients best interests at heart, this can be revoked by the surgery at any point.
You may also revoke this consent to share information with third parties at any point. You do not need to inform your representative of this.
Confirmation of this account being activated will be sent back via email, you must ensure you routinely check your emails for surgery correspondence.