Permission to share and leave messages



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PERMISSION TO SHARE AND LEAVE MESSAGES

All information held at the Practice about patients is confidential, whether held electronically or in hard copy.


Staff must not, under any circumstances disclose patient information to anyone outside the Practice, except to other health professionals on a need to know basis, or where the patient has provided written consent. (Please ask a receptionist for patient leaflet: How we use your Health Records, if you would like more information).
All patients can expect that their personal information will not be disclosed without their permission (except in the most exceptional circumstances when, for instance disclosure is required when somebody is at grave risk or serious harm).
In accordance with the Data Protection Act 1988, Weston Lane & Harefield Surgeries requires written consent from any patient who is happy for messages to be left on their answer phone in the event that the Practice may need to contact them. If we do not have written consent, we are unable to leave a message on any answer phone or with a third party.
If you would like to consent, please complete the following:

I CONSENT TO




  1. I give consent for Weston Lane & Harefield to leave messages on my answer phone at the following numbers:




Number

Home

Work

Mobile

Other




a)

     












b)

     












c)

     















  1. I give consent for Weston Lane & Harefield to send text message: 




  1. I give consent for Weston Lane & Harefield to leave messages about any aspect of my medical treatment with

the following third party:




Name

Relationship




a)

     

     




b)

     

     







Can these people pick up prescriptions on your behalf? a) Yes  b) Yes 




Signed:




Printed:















Address:

     







     







     













P/code:

     





























IF YOU WANT YOUR CONSENT TO CEASE
Please contact a receptionist if you would like this consent to cease. An acknowledgement of your cease to consent will be sent to you at the address we hold on record for you. Our contact telephone numbers are:

Weston Lane 02380 449913, Harefield 02380 472816


Weston Lane & Harefield Surgeries Permission to share and leave messages

Reviewed: May 2015




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