Removal Or Update Of Consent




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Personal Details
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I am a patient of Castlegate and Derwent Surgery and I have previously given consent for another individual to have access to my medical records and/ or to discuss my medical requirements. I wish for their details to be updated or removed from my medical record.

Contact details for the individual who I wish to remove from my medical record
New contact details for the individual who 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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