Patient consent to medical records access

Personal Details

The person whose records another individual(s) is to be given access to

Patient Full Name: *

Telephone Number:

Address: *

Is the patient a child under the age of 16? *

Yes

No

Details of the Person to be given access to this Patient’s information

Your Full Name: *

Your Relationship to the Patient: *

Telephone Number:

Address: *

Do you wish to be granted full access? *

Yes

No

Please detail below if your access is to be limited in any way (e.g. only for test results, or only for making & cancelling appointments, or for a specified time period only): *

Declaration

*

I confirm that I give permission for the Practice to communicate with the person identified above in regards to my medical records.

Signature: *

Date:

Consent for children under 16 (Gillick Competence)

Consent for children under 16

Everyone aged 16 or more is presumed to be competent to give consent for themselves, unless the opposite is demonstrated.

If a child under the age of 16 has ‘sufficient understanding and intelligence to enable him/her to understand fully what is proposed’ (known as Gillick Competence), then s/he will be competent to give consent for him/herself.

Young people aged 16 and 17, and legally ‘competent’ younger children, may therefore sign this Consent Form for themselves, but may wish a parent to countersign as well.

If the child is not able to give consent for him/herself, someone with parental responsibility should do so on his/her behalf by signing this Form below.