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Patient Test Results Consent Form

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If you wish to give permission for a third named person to receive results on your behalf please complete this form

Our reception staff are trained to give out results of some diagnostic tests which have been reviewed by the Doctors on their instructions.
Staff will not give results to any third party, including a spouse or close relative unless written permission has been given by you.
Details will be recorded on your medical record to alert staff and allow disclosure.

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All questions marked with a * are mandatory

Your Details

Please double check you've entered the correct email address

May be used to identify you

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Named Person for consent

Is the person a patient at this surgery?:

Consent

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Privacy Consent

This form collects personal and medical information about you and we use this information to allow the practice team to contact you.
Please read our Privacy Policy to discover how we protect and manage your submitted data.

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