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 -

Invites for the Spring Covid Booster for those aged 75 and older or are immunosuppressed will be sent out centrally. You should be offered an appointment around 6 months (and not b... Find out more

Important -

Covid Travel Passes Please arrange your Covid Travel Pass as soon as you make holiday plans. The easiest way to get the Travel Pass is to download the NHS App for anyone aged 13 o... Find out more

Important -

See the latest newsletter: Newsletter February 2022