Patient’s Name	 
 	
Patient’s Address

 

To: Jenner House Surgery 

I give permission for my Carer [Insert Carer Name] to have access to my medical records and personal details held by the Practice.

This permission relates to all / part of my record / specific condition only (delete as appropriate).

Where the permission is restricted to part of the record only, please specify below the precise limits of this permission, and any areas of the record which are excluded.

_________________________________________________________________________________________________________________________________________________________________________________________________________________________________

I understand that the doctor may override this authority at any time, and that this permission will remain in force until cancelled by me in writing.

I consent to my Carer receiving copies of all correspondence relating to my treatment (delete if not applicable). I confirm that this has been explained to me by my GP and that the GP has sole discretion to withhold all or any copies.

Signed _______________________________ (Patient)

Date _________________________________

Accepted by ___________________________ (Doctor)

Date _________________________________

Office Use Only:
Copy Frequency	 	
Specific Copy Exclusions	 	
Specific Copy Inclusions	 	

AGREEMENT FOR A CARER TO HAVE ACCESS TO A PATIENT’S PERSONAL DETAILS and/or COPIES OF CORRESPONDENCE