Consent to share medical information Name Home phone number Mobile number Are you happy for us to leave an answerphone message? Yes No Are you happy to receive text messages from us? Yes No Email address Ar you happy to be contacted via email? Yes No Do you have a next of kin? Yes No If so, please provide their name, relationship to you and their contact details Due to confidentiality and data protection we are unable to discuss your medical record with anyone other than you unless you have provided written consent. Young people over the age of 13 will need to fill out a consent form for parents/guardians to be able to speak on their behalf and we require the main contact number on the notes to be their own not their parents. I hereby give consent for my:Test r Please select the options you give consent for Test results (blood test, x-rays, us scans etc) Doctor/Nurse appointments Prescriptions/medication Any other information pertinent to my medical care To be discussed with the following people: Please provide name, relationship to patient and their contact details Consent Consent