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 have now completed 1425 vaccinations and continue to receive further supplies of vaccines and are now completing vaccinations of over 80s who are able to come up for a vaccine, ... Find out more

Important -

We are not running any covid vaccination clinics this week as we have not received any vaccines but as soon as we are advised that we are due vaccines we will continue with our vac... Find out more

Important -

We have been asked by NHS England to start delivering the COVID-19 mass vaccination programme from 16 December. This will be done by working together with other local GP Practices ... Find out more