Third Party Consent

If you wish to register a third party for representation, please submit this form.

If you change your mind, please contact the practice.

Please be aware that any replies from the surgery may appear in your Junk Inbox.

Third Party Consent

Third Party Consent

Patient Details

Third Party

I hereby authorise:
To discuss my care and medical records and act on my behalf in relation to the healthcare I receive from Fakenham Medical Practice.

I also fully consent to Fakenham Medical Practice disclosing to the person named above any information including personal data held by Fakenham Medical Practice for the purpose of providing this service.

Please update my records accordingly. I will notify Fakenham Medical Practice should I change my mind.