Consent

Occasionally you may want someone to be able to discuss your medical records with us. This could be a partner, relative or friend. Please consider this carefully, as if you provide consent for a named person, they will be able to discuss elements of your medical care with us. If you would like someone to be able to discuss your care with us, without us requiring additional consent, please provide their details below.

For children aged 13 and younger, we will only discuss their care with people deemed to have parental responsibility unless otherwise stated.

We reserve the right to refuse access to anyone other than the individual, the medical record pertains to if there are grounds that providing access is likely to cause serious physical or mental harm to the patient or the information you have asked for contains information that relates to a third person.

Please select the practice location most relevant to this Online Form submission:

Your Details

Title

First Names

Surname

Date of BirthDD/MM/YYYY

NHS Number (if known)

Find my NHS Number (opens in new window)

Home Address

Postcode

Telephone

Mobile

E-mail Address

Details for the named person

Title

First Names

Surname

Date of BirthDD/MM/YYYY

NHS Number (if known)

Find my NHS Number (opens in new window)

Relationship

Telephone Number

Does the carer hold legal power of attorney?

Yes

If yes please provide a copy of the legal documents to the surgery.

I want the person to be able to discuss

Medication Test Results Referrals Full Medical Record

I understand I have given consent for the above, named individual to have access to my medical records, to discuss those matters indicated above. I understand I can withdraw this consent at anytime but must provide written notification to the surgery for this to happen.

Privacy Protection

Information submitted through secure forms is used only for the purposes of processing your request. We may be in touch with you in relation to the information submitted.

All Information submitted through secure forms is secured with a private key and is accessed over a secure connection by nominated staff. We have a strict confidentiality policy.

This information is not shared with any third party organisations.

This information is retained for up to 28 days.

I consent to my information being used for the purposes described above and wish to submit this online form to Gold Street - Main Surgery • Gold Street, Saffron Walden, Essex, CB10 1EJ.

Learn more about our Privacy Policy and Terms of Use. Should you have any concerns about sending your personal details using the web, please use one of the alternative methods offered by our organisation.