FORM OF AUTHORISATION

Name:	………………………………………………………………….

Address:	………………………………………………………………….

		………………………………………………………………….

Date of Birth:  	………………………………

Telephone No.:	………………………………

GP Name:		………………………………

I HEREBY give my consent for the release of information/copies of my medical records to:

Name:	………………………………………………………………….

Address:	………………………………………………………………….

		………………………………………………………………….

Date of Birth:  	………………………………

Telephone No.:	………………………………

GP Name:		………………………………

For the purposes of a medical report:

I DO/DO NOT WISH TO SEE THE REPORT BEFORE IT IS SENT

SIGNED: ………………………………    DATE: …………………………