Release of Medical Information to Relative/Carer Consent Form Your detailsFull NameDate of Birth DD slash MM slash YYYY Address (Including Postcode)Phone Number OptionalDetails of the person you give consent toConsent I hereby consent to the release of my medical information for the purpose of my further medical care to the below person.Full NameAddress (including Postcode)Home Phone, if differentMobile Phone, if differentRelationship OptionalAre you registered at the practice? Yes No Consent I declare that the information provided on this form is correct to the best of my knowledge I consent to being contacted via the details given above. I agree to the privacy policy