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

If you are human, leave this field blank.

Third Party

I hereby authorise:

Full name of third party: *

Relationship to you: *

Phone number of third party:

Home Address (including postcode) *

To discuss my care and act on my behalf in relation to the healthcare I receive from Watership Down Health and other third party health and social care providers that Watership Down Health may have been made aware of. Such as referrals and results from hospitals.

I also fully consent to Watership Down Health disclosing to the person named above any information including personal data held by Watership Down Health in relation to the care received from Watership Down Health and wider health and social care providers.

Please update my records accordingly. I will notify Watership Down Health should I change my mind.

Signature: *

Date:

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Third Party Consent

Third Party

Statement on Accessing the Practice