Birchwood Medical Practice
Jasmin Road, Lincoln, LN6 0QQ
Tel:  01522 699999

Consent to Discuss Medical Record Information with Specified Person

By completing this form you are granting the Birchwood Medical Practice permission to speak to the specified Carer/Relative(s) in relation to the selected topics stated below.

It is your responsibility to contact the practice immediately if you wish to revoke your consent, as consent will be valid unless advised otherwise. 

Patient Name	 	
NHS Number	 	
Address		
Date of birth	 	

Person(s) who you wish to allow access:
Full Name	 	
Address & Contact 
Number	 	
Relationship
to Patient		
Consent to discuss and have access to (please circle)	Medical Records / Treatment Plans / Medications / Appointments / Results	

Full Name	 	
Address & Contact 
Number	 	
Relationship 
to Patient		
Consent to discuss and have access to (please circle)	Medical Records / Treatment Plans / Medications / Appointments / Results	

Signature of patient……………………………………………………. Date……………………....