Application for third-party access to healthcare information

To maintain confidence in our patients, at Thornbury Road Centre for Health we will not divulge any medical information about you unless it is legally appropriate, or we have your consent to do so.

Who should complete this form?

  • Anyone OVER 16 who is competent to do so
  • Children aged 13 – 15 who have been assessed as competent by the GP. 


Should you wish to consent for a nominated person to be able to discuss any medical information about you with staff at this practice, please indicate this in the form overleaf.

Although by completing this form, the following should be noted:

  • The person granting access to a third-party must fully complete and sign the form
  • Any incorrectly completed forms will not be processed and will be returned to person making the application
  • This form does not permit any third-party individual to make healthcare decisions on behalf of the named patient
  • This practice may contact you via email or telephone should there be any concern

Non-urgent advice: Disclaimer

It is also your responsibility to keep us informed as to who can access and discuss specific areas of your medical record as detailed on the form. Should your circumstances change, it is your responsibility to advise this practice.

Thornbury Road Centre for Health relinquishes all responsibility should the above information become incorrect if not updated.