Consent to Medical Records Access Form




Please complete our online form

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Patient’s Details

I am a patient of Castlegate and Derwent Surgery and understand I need to give consent for another individual to have access to my medical records and/ or to discuss my medical requirements. I understand the contact details of the individual will be recorded on my medical record.

Contact Details for the Individual to whom I wish to grant access

Privacy Consent

This form collects personal and medical information about you. We use this information to allow the practice team to contact you. Please read our Privacy Policy to discover how we protect and manage your submitted data.


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