Consent to Disclosure of Confidential Medical Information

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Incorrect information in your records

Incorrect information in your records

On rare occasions information in your records might be incorrect.

  • If you find any incorrect information you should let the surgery know as soon as possible.
  • If you see information about anyone else in your records, log out immediately and let the surgery know as soon as possible.
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Details of the Patient
Title: *
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Details of the applicant
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Please tick the statement applicable(s)
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Signature

I am aware that this consent may be revoked by me at any time.

  

Privacy Consent

This form collects personal and medical information about you. 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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