Patient Authorisation and Consent for a Representative | Old Coulsdon Medical Practice

Online Requests

If you would like to nominate a representative to collect prescriptions, or correspondence for you, please let the surgery know who in this form.

Patient Authorisation and Consent

Patient Authorisation and Consent

If you are human, leave this field blank.

Patient Details

Title *

Mr

Mrs

Miss

Ms

Last Name *

First Names *

NHS Number

Contact Number *

Full Address *

Postcode *

Collect Prescriptions/Correspondence

Only complete this section if applicable.

I consent for my prescription/correspondence to be collected on my behalf by the person listed below.

Full Name

Contact Number

Full Address

Postcode

Communicate with the Practice regarding my Medical Records

Only complete this section if applicable.

I consent for my representative to communicate with the Practice regarding my medical records. The details of my Representative are as below:

Full Name

Contact Number

Full Address

Postcode

Patient Signature *

Print Name *

Date

Important -

We are currently experiencing problems with our phone lines but this is being investigated and hopefully will be sorted by Tuesday. If it is for a general enquiry and not to boo... Find out more

Important -

Over 45’s can now book a vaccination direct by contacting 119 or online through www.nhs.uk/conditions/coronavirus-covid-19. We are continuing to run weekly clinics at the Old ... Find out more

Important -

We are delighted to inform you that all patients in group 1-9 should now have received an invite for their first covid vaccination either by Old Coulson Medical Practice or central... Find out more

Important -

We are only receiving Oxford -Astra Zeneca vaccines at the moment and believe this to be the case locally. When we do receive some Pfizer vaccinations in, these will be for the 2nd... Find out more