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Online Forms

Two Week Wait Patient Information

This form provides patients with information about their two-week wait referral and what to expect from this process.

 

Consent To Release Confidential Medical Information To A Third Party Form

Consent To Release Confidential Medical Information To A Third Party Form

This form will need to be completed and returned to the Surgery by the patient as they will be required to provide ID to enable the Surgery to update their records for releasing information to their nominated person.

This form when completed grants a nominated third party permission to discuss aspects of a patient's medical information with staff at the Surgery. Please make sure that when completing the form you only grant access to the aspects of your medical record you wish to disclose (i.e. prescriptions, medical records etc.) Patients should also note that when consent is given via this form it is enduring and the Practice should receive written notification from the patient if they wish to rescind the permission at any time. 

 

Change of Personal Details Form

Change of Personal Details (added August 2021)

Please complete this form if you have changed address, any contact details (email/telephone or mobile number) or if you have changed your name (marriage, deed poll or divorce). This form will need to be printed, signed and brought to the Surgery along with requisite documentation to prove the changes.

 

Subject Access Request Form

Subject Access Request Form (added August 2021)

If you are completing this form for yourself it can be completed and sent electronically to Emma.Wright93@nhs.net

If you are completing this form on behalf of someone else for the information to be disclosed to you it will need to be submitted in person at the Surgery by the patient themselves as we will require proof of ID and consent to enable us to release their medical records to a third party. Please note this will not be necessary if consent has already been granted by the patient to release information to a nominated third party and the nominated third party being the same person named in the Subject Access Request Form. This is usually done through the Consent To Release Confidential Medical Information To A Third Party Form which is available online (please see above) or copies are available to collect at the Surgery.

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