Occasionally you may want someone to be able to discuss your medical records with us. This could be a partner, relative or friend. Please consider this carefully, as if you provide consent for a named person, they will be able to discuss elements of your medical care with us. If you would like someone to be able to discuss your care with us, without us requiring additional consent, please provide their details below.

For children aged 13 and younger, we will only discuss their care with people deemed to have parental responsibility unless otherwise stated.

We reserve the right to refuse access to anyone other than the individual, the medical record pertains to if there are grounds that providing access is likely to cause serious physical or mental harm to the patient or the information you have asked for contains information that relates to a third person.

Your Details

If Known

Details for the named person

If Known

If yes please provide a copy of the legal documents to the surgery.

Privacy Protection

Information submitted through secure forms is used only for the purposes of processing your request. We may be in touch with you in relation to the information submitted.

All Information submitted through secure forms is secured with a private key and is accessed over a secure connection by nominated staff. We have a strict confidentiality policy.

This information is not shared with any third party organisations.

This information is retained for up to 28 days.

Learn more about our Privacy Policy and Terms of Use. Should you have any concerns about sending your personal details using the web, please use one of the alternative methods offered by our organisation.

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Smith & Schwarz Opticians