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 -

Due to the COVID-19 pandemic, this year we will be holding flu clinics at the Old Coulsdon Congregational Church (next door to the surgery). Please be assured that we will be oper... Find out more

Important -

If the GP/Nurse has advised you to visit the surgery, we ask that any patients over the age of 5 wear protection over their mouth and nose. This could be a mask or a homemade face ... Find out more