Parkwood Drive Surgery
Warners End, Hemel Hempstead, Hertfordshire HP1 2LD
Telephone : 01442 250117 Fax : 01442 256185
CONSENT TO DISCLOSE CONFIDENTIAL MEDICAL INFORMATION
Name: _______________________________ Date of Birth: ______________________
Address: _______________________________________________________________
I hereby consent to the disclosure of my private medical information to:
Name: _______________________________ Date of Birth: ______________________
Relationship: __________________________ Tel. No:___________________________
Address: _______________________________________________________________
Please tick the statement/s applicable:
Full and open ended disclosure of any matter related to my medical record
Full disclosure of any matter related to my medical record for the period
(From) _________________________ (To) ______________________
Limited disclosure of the following aspects of my medical record:

Test Results
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Prescription queries
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Appointment queries
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Referral queries
N
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m
e
:
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_ record, please state: _____________________
 Any other matter related to my medical
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I am aware that this consent may be revoked
by me at any time.
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Signature: _______________________________
Date: ______________________
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Witnessed by (not the individual for whom_consent is being granted):
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Name: _______________________________
Signature: _____________________
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Address: ____________________________________________________________
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_ form please ask the Receptionist.
If you need assistance in completing this
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Dr R J Gallow, Mr M A Peck, Dr T D Fernandes, Dr J C Brazier,
_ Dr S Stier, Dr H Antscherl, Dr G Solomons
Dr G Y White, Associate GP, Dr P Oliver, Associate GP, Dr C Ward, Associate GP, Dr H Pattinson, Associate GP
_ Nina Booth, Patient Services Manager : Ms Carol Edwards
Practice Manager : Mr Colin Neal, Asst Practice Manager : Mrs
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