Next of kin consent

Full Name:

Date of Birth:

Please use format DD/MM/YYYY

Email Address:

NHS Number:

Address:

I wish to give consent to allow disclosure of information to the following person

I wish to revoke consent to allow disclosure of information to the following person

Full Name:

Date of Birth:

Please use format DD/MM/YYYY

Full Address:

Post Code:

Relationship to Patient:

Are they also registered at Tuxford Medical Centre?

Yes

No

Are there any restrictions on information that can be discussed?

e.g. Test results, only, only information regarding a specific condition, etc

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