Consent to Share Records

Patients have a right to request access to their own medical records and can also provide consent for disclosure to third parties. Please use this form if you are over the age of 16 years and give consent for a family member or give consent to a relative or third party to have access to the medical records and personal details held by The Barcellos Family Practice.

Last Updated: 09/08/2023

Details of patient making the request

These are the details of the patient providing permission for a relative or other third party to access your medical records and personal details held by The Barcellos Family Practice.

Your full name *

Your Date of Birth (dd/mm/yyyy) *

Your current address including post code *

An email address on which we can contact you *

A mobile phone number on which we can contact you

Your landline phone number

Details of the third party to be given access to your records

These are the details of the relative or third party to whom you are giving permission to access your medical records and personal details held by The Barcellos Family Practice.

Their full name *

Their relationship to you *

Their postal address *

Their home landline number *

Their mobile telephone number

Patient Consent

The Practice has a duty to protect the confidential data of our patients under the Data Protection Act (1998). By completing this form, you are authorising the Practice to share your confidential data with someone else, a third party. Patients requesting third party access to their records need to be aware of the potential consequences and be clear about exactly what part/s of their records the consent applies to.

Patients should note that it is their responsibility to notify the Practice, in writing, if they have any concerns, change their mind or no longer wish for the said third party to access their records in the future for any reason.

Consent to share *

I give permission for the person listed above to access my medical records and personal details held by The Barcellos Family Practice.

Acknowledgement *

have read and understood the above and I acknowledge that it is my full responsibility to notify the Practice if I wish to make any changes to or withdraw this consent.

THIS FORM COLLECTS YOUR NAME, DATE OF BIRTH, EMAIL, OTHER PERSONAL INFORMATION AND MEDICAL DETAILS. THIS IS TO CONFIRM YOU ARE REGISTERED WITH THE PRACTICE, TO ALLOW THE PRACTICE TEAM TO CONTACT YOU AND ALSO TO UPDATE YOUR MEDICAL RECORDS HELD BY THE PRACTICE AND OUR PARTNERS IN THE NHS. PLEASE READ OUR PRIVACY POLICY TO DISCOVER HOW WE PROTECT AND MANAGE YOUR SUBMITTED DATA *

I consent to the practice collecting and storing my data from this form.

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Consent to Share Records

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