Patient Consent

Section

Details of person to be able to discuss your care

Is the above person your next of kin?
Note: Next-of-kin persons closest living blood relative or relatives. In case of medical emergency, where a person is incapable (either legally because of age or mental infirmity, or because they are unconscious) of making decisions for themselves and they have no spouse of children, medical decisions can be made by next-of-kin in preference to the wishes of medical personnel.
e.g., only for test results, or only making & cancelling appointments, or for a specific time period only
Would you like to give another person permission to discuss your care?

Details of person 2 to be able to discuss your care

Is the above person your next of kin?
Note: Next-of-kin persons closest living blood relative or relatives. In case of medical emergency, where a person is incapable (either legally because of age or mental infirmity, or because they are unconscious) of making decisions for themselves and they have no spouse of children, medical decisions can be made by next-of-kin in preference to the wishes of medical personnel.
e.g., only for test results, or only making & cancelling appointments, or for a specific time period only

If you would like to give more persons permission to discuss your care, please complete another form.

Confirmation

I confirm that I give permission for staff at Coltishall Medical Practice to discuss my medical care with the person/s named above. I also confirm that it is my responsibility to withdraw consent when required.

If the patient does not have capacity to consent to another discussing their medical care but access is considered by the practice to be in the patient’s best interest, please leave the signature blank. This form then may be signed by the GP.

Enter full name