Third Party Consent

If you wish to register a third party for representation, please submit this form.

In order to verify your request, you will be contacted by telephone to confirm your identity. Please note, in some instances you will be required to provide identification to the practice.

If you change your mind, please let reception know.

Third Party Consent

If you are human, leave this field blank.

Patient Details

Third Party

I hereby authorise:

Full name of third party: *

Relationship to you: *

Phone number of third party:

Home Address (including postcode) *

To discuss my care and medical records and act on my behalf in relation to the healthcare I receive from St Stephen's Gate Medical Practice.

I also fully consent to St Stephen's Gate Medical Practice disclosing to the person named above any information including personal data held by St Stephen's Gate Medical Practice for the purpose of providing this service.

Please update my records accordingly. I will notify St Stephen's Gate Medical Practice should I change my mind.

Signature: *

Date:

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