Authorising parental access to medical records for 11-15 year olds

In order to comply with guidance on confidentiality, young people aged 11-15 years old must give consent for adults with parental responsibility to access their medical records. Please complete the form below if you would like an adult to have access to all your medical records including results and medication. This permission lasts for one year and another form must be completed annually. You can withdraw consent at any time by contacting the surgery on by telephone 01245 221777, by email reception.f81100@nhs.net, or by writing to the admin department at your usual branch.

Last Updated: 22/09/2020

Declaration

Full Name *

Date of Birth *

Date (valid for 1 year)

I give permission for the below named people to have access to my medical records including results for the next calendar year. I understand that I can cancel this permission at any time. *

Signature

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Authorising parental access to medical records for 11-15 year olds

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