Consent Form

We recommend that after the age of 16 you are the main point of contact in your health care but understand that you may still want your parent or guardian to speak on your behalf, so if you have their number as the alternative contact you know that their number will still be on your record but all correspondence including appointment reminders and details about any treatment will come directly to you.

Your Name

First Last

Your Phone Optional

Your Email Optional

Your Address

Street Address Optional Address Line 2 Optional City Optional County / State / Region Optional Postal Code Optional Country Optional

I reserve the right to reverse any decision I make in granting access to my records at any time and it will automatically be removed when I reach 16 unless an alternative date is specified. I understand the risks of granting someone such access to my health records.

Chosen person's Name

First Last

What is your relation to this person?

Chosen Person's Address – If not the same as yours.

Street Address Optional Address Line 2 Optional City Optional County / State / Region Optional Postal Code Optional Country Optional

Chosen Person's Phone Optional

Chosen Person's Email Optional

Is this person the main point of contact?*

Me as main point of contact

Chosen person as main point of contact(Parent/ Guardian)

*This person will receive all calls and messages from the practice. We would advise the patient to be main point of contact not a parent or guardian when the patient if over 13.

Chosen contact what information would you like us to share with them?

Full consent(to discuss everything in medical records/ history)

Appointments

Medication ordering

Consent will automatically be removed when you turn 18 years old.

You can withdraw consent before this by contacting the practice and speaking to the staff.

Patient Signature Optional