Tell us whether you accept cookies

We've put some small files called cookies on your device to make our site work. We would also like to use analytical cookies to understand how our site is used and improve user experience. Analytical cookies send information to Google Analytics.

Let us know your preference. We will use a cookie to save your choice. Before you make your choice you can read more about our cookie policy.

Bedford Street Surgery NHS GP Surgery in Milton Keynes

Carer’s medical records access request

Carers Medical Record Access Request

Section

Patient’s Address: *

Details of Access

Carer / Support Worker / Nominated individual Name: *

I give permission for my Carer / Support Worker / Nominated individual named above to: *

Full access to my medical records and discuss my care

Restricted access to my medical records and discuss my care

Book / Cancel / Enquire about appointments: *

Yes

Discuss my test results: *

Yes

Discuss my medication: *

Yes

Discuss my current needs / concerns with the practice staff: *

Yes

This permission relates to: *

My entire record

A specific condition only

Please specify the condition details: *

Please read and confirm the following: *

I confirm that I give consent for my Carer / Support Worker / Nominated individual named above to access my Medical Records and information relating to my care as stated above

I understand that the practice may override this authority at any time, and that this permission will remain in force until cancelled by me in writing.

Patient Signature: *

Date:

If you are human, leave this field blank.

Bedford Street Surgery
4 Bedford Street
Bletchley
Milton Keynes
MK2 2TX

Get directions

01908 658 850

Furzton Medical Centre
67 Dulverton Drive
Furzton
Milton Keynes
MK4 1EW

Get directions

01908 658 850

Feedback and complaints

Wellbeing

Accessibility statement

Website policies