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 will be in touch with all patients eligible for either the flu vaccine or their covid booster in due course. We will be vaccinating patients in accordance with the published ... Find out more

Important -

We have now received our flu vaccines supply, so we can go ahead with the Flu vaccination Clinic on the mentioned dates. Saturday 11th September from 09:00 - 16:00 Thursd... Find out more