Patient Consent Form

To authorise another person to receive medical information on your behalf

Church Street Practice Authority for the Practice to share your medical information with a nominated person

Patients’ Right to Confidentiality

Patients have a right to expect that information about them will be held in confidence by their doctors and all practice staff. Confidentiality is central to trust between doctors and patients. Without assurances about confidentiality, patients may be reluctant to give doctors the information they need in order to provide good care.

The duty of confidentiality owed to a person under 16 is as great as the duty owed to any other person. Confidentiality is the cornerstone of health care and central to the work of everyone working in general practice. All information about patients is
confidential, from the most sensitive diagnosis, to the fact of having visited the surgery or being registered at the practice.

All members of the Church Street Practice take patient confidentiality very seriously

All patients can expect that their personal information will not be disclosed without their permission except in the most exceptional of circumstances when it may be necessary to share information even though the individual has not consented. Information can be shared without the consent of the person whom the information is about when:

  • It is in the public interest to do so e.g. where a child or anyone else is believed to be at risk of harm, and
  • It is required by law e.g. notification of certain infectious diseases and information required by a Court Order.

Church Street Practice Staff Confidentiality Agreement

To demonstrate our commitment to maintaining patient confidentiality, all members of staff sign the Practice Confidentiality Agreement which states:

Quote / Testimonial:
“I understand that all information about patients held by this practice is strictly confidential, from the most sensitive diagnosis, to the fact of having visited the surgery or being registered at the practice.

I also understand that the duty of confidentiality owed to a person under 16 is as great as the duty owed to any other person.

I have read and understood the practice’s Confidentiality policy and agree to be bound by its terms.

I will not disclose personal information learnt in the course of my employment to anybody outside the practice. If I feel disclosure is necessary in the interests of a patient, his or her family, or the public, I will inform the patient beforehand, unless to do so would be dangerous for the patient or others.

I have received information and training on this matter and understand that a breach of this obligation may result in my dismissal.”

Patient Responsibility

We ask you to understand that we are protecting the patient’s confidentiality if we refuse to give you any information about another person. If you want us to be able to give information to a relative, friend or carer please send us a written instruction or complete the form overleaf. You may authorise us to give your appointed representatives any medical information that they
request or limit this to any particular area e.g. test results, as you wish.