Information Sharing Consent Form

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NHS

Your Personal Information

This form outlines your permission for us to share your personal information with relevant service providers involved in your care. This may include accessing and sharing your medical records, and where applicable, your mental health and police records.

Your consent to share personal information is entirely voluntary and you may withdraw your consent at any time.

  More information about how we use your data

You can use this form to:

  • Provide or withdraw your consent for sharing your personal information with relevant service providers involved in your care.

This decision will not affect individual care and you can change your choice at any time, using this form.

 
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Information Sharing

Your Permission

I hereby give my permission for Redgate Medical Centre to share personal information with other service providers in connection with my care, including accessing and sharing my medical, and if applicable, mental health and police records.

I understand that Redgate and Somerset Bridge Medical Centres may hold information gathered about me from the various agencies and as such my rights under the Data Protection Act will not be affected.

Statement of Consent:

  • I understand that personal information is held about me.

  • I have had the opportunity to discuss the implications of sharing or not sharing information about me.

  • I agree that personal information about me may be shared and gathered from the following agencies:

- The Pharmacy currently prescribing weight loss medication to me

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Patient Details
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Declaration

Please return to the previous pages to make any amendments

Privacy Consent

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