Young People Consent to Share Information Form

Young People Consent to Share Information Form

 

  • Purpose of this form

    Now that you are over 16 years old, you are considered able to manage your own healthcare. Because of this, we will need your consent to discuss any medical matters with anyone other than yourself.

    If you would like your parent/guardian to remain able to access your medical information, please complete the enclosed form to give your consent. You can change this at any time by contacting the practice.

    Under your details please include the primary phone number you would prefer to be contacted on.

  • Patient details

  • I give consent to the following people...

    Please give details of those you wish to give consent to.

    Permissions granted (optional)
    Permissions Granted (optional)

  • I do not wish anyone to access my information on my behalf

    Please confirm if you do not want anyone other than yourself to have information about your medical information.

    I confirm I am the only one able to access my medical information (optional)

  • Declaration

    I confirm that I understand I am now responsible for my own healthcare and who I choose to share my medical information with.

    I give my consent for any person(s) named on this form (if completed) to be contacted by the practice and to act on my behalf regarding my healthcare.

    I understand that I can withdraw consent at any time by informing the practice, and it is my responsibility to let the practice know if I no longer wish this consent to remain in place or if my contact details change.

    Agreement (in lieu of signature)
This form is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.
Page last reviewed: 31 March 2026