Release of Medical Information to Relative/Carer Consent Form Release of Medical Information to Relative/Carer Consent Form Your DetailsFull NameDate of Birth DD slash MM slash YYYY Address (including postcode)Mobile Phone OptionalDetails of the person you give consent to.I hereby consent to the release of my medical information for the purpose of my further medical care to the below person. OptionalFull NameAddress (including postcode)Home Phone (if different) OptionalMobile Phone (if different)Relationship OptionalAre you registered with the pracitce? Yes No ConsentI declare that the information provided on this form is correct to the best of my knowledge I consent to being contacted via the details given above. I agree to the privacy policy