Gp Consent Letter Template UK

The GP Consent Letter Template UK is offered in multiple formats, including PDF, Word, and Google Docs, and comes with editable and printable versions for your convenience.

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Sample

Gp Consent Letter Template UK

Editable – Printable

PDF – 1 PDF – 2

GP Consent Letter Template UK

1. Patient Information



2. GP Information


3. Consent Purpose

4. Details of Information to be Shared

5. Duration of Consent

6. Recipients of Shared Information

7. Patient Rights

8. Withdrawal of Consent

9. Signatures



PDF

WORD

Examples

GP Consent Letter Template UK (1)
Between:
[Patient’s Name]
[Patient’s Date of Birth]
[Patient’s Address]
[Patient’s Phone]
[Patient’s Email]
And:
[GP’s Name]
[GP’s Practice Name]
[GP’s Address]
[GP’s Phone]
[GP’s Email]
Introduction:
This consent letter grants permission for [GP’s Practice Name] to disclose and share medical information regarding [Patient’s Name] with [Specify Recipient’s Name or Organization], in accordance with UK data protection regulations.
Clause 1: Purpose of Disclosure
The information shared will be used for the following purposes: [Specify purposes, e.g., referral to a specialist, insurance claim processing, etc.].
Clause 2: Type of Information to be Shared
The consent includes the sharing of the following types of medical information: [Specify types of data, e.g., medical history, test results, treatment plans, etc.].
Clause 3: Duration of Consent
This consent is valid until [Specify end date or state ‘until revoked in writing’] and can be withdrawn by the patient at any time by providing written notice.
Clause 4: Confidentiality and Data Protection
The GP’s practice will ensure that all disclosed information is treated confidentially and in accordance with the UK’s GDPR regulations.
Clause 5: Acknowledgment of Understanding
By signing this letter, I acknowledge that I have read and understood the contents of this consent letter, including the purpose and implications of sharing my medical information.
Signed in [City], [Date].
Sincerely,
[Signature of the Patient]
[Patient’s Name]
[Signature of the GP]
[GP’s Name]
GP Consent Letter Template UK (2)
Between:
[Patient’s Name]
[Patient’s Date of Birth]
[Patient’s Address]
[Patient’s Phone]
[Patient’s Email]
And:
[GP’s Name]
[GP’s Practice Name]
[GP’s Address]
[GP’s Phone]
[GP’s Email]
Introduction:
This letter of consent allows [GP’s Practice Name] to share medical records of [Patient’s Name] with [Specify Recipient, e.g., healthcare provider, insurance company], ensuring compliance with applicable privacy laws.
Clause 1: Nature of Information
The types of information to be shared include: [List specific health records, notes on consultations, and previous treatments].
Clause 2: Consent Validity
The consent provided via this letter remains valid until [Specify duration] or until retracted by the patient through a written notification.
Clause 3: Right to Withdraw Consent
The patient retains the right to withdraw this consent at any time, without affecting the legality of sharing information prior to withdrawal.
Clause 4: Third-Party Disclosure
The GP’s office will not disclose the shared information to any third parties without prior written consent from the patient.
Clause 5: Contact for Queries
For any queries regarding this consent letter or the information shared, please contact [Contact Name/Department] at [Contact Information].
Signed in [City], [Date].
Sincerely,
[Signature of the Patient]
[Patient’s Name]
[Signature of the GP]
[GP’s Name]

Printable

PDF – 1 PDF – 2

Gp Consent Letter Template UK