LETTER OF CONSENT TO ACCESS MEDICAL INFORMATION
PLEASE USE A BLACK PEN
CONSENT TO ACCESS MEDICAL INFORMATION AND SHARING OF DATA
Child/Young Person……………….……………………....………………..DOB ………………
Address……………………………………………………………………………………………… …………………………………………………………………………………………………………
I,……………………………………………Parent/Guardian/Young Person hereby give my consent for a representative from Chestnut Tree House to access the medical records on behalf of my son/daughter ……………………………………………………………………….
This will assist them in gaining information to help process the referral. I/We have consented to be referred to their services. I understand that no information can be accessed without my written consent.
I confirm that I have also received a copy of the Family Information Leaflet ‘Personal Information and How We Use It’ and understand the contents and implications of the information contained therein.
Signed …………………………………………………. Date ………………………………..
Parent/Guardian/Young Person
Signed …………………………………………………. Date ………………………………..
(To be signed by a member of Chestnut Tree House staff)
Role ……………………………………………………
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