Authorisation for Access to Patient Records form - Collingham Church View Surgery & Thorner Surgery

Tel: 01937 222 841 Out of hours: 111 Log in to SystmOnline

If you wish to give another person (perhaps a family member) access to your medical records, please complete this form.

(* = required field)

Patient Name *

Date of birth *

NHS number *

Email address *

I hereby give permission for the following person(s):

Name *

Relationship *

Contact details *

To have access to the following information from my medical records: *

Appointment information

Prescriptions and medication

Consultations

Test results

Referrals / Hospital Correspondence

Other (please specify)

Patient Signature *

Name

Training Days

On the following dates the surgery will be closed from 1pm for training and will re-open the following day at normal hours:

Thursday 2^nd July 2026
Thursday 10 September 2026
Thursday 8^th October 2026
Thursday 5^th November 2026
Thursday 14^th January 2026
Thursday 4^th February 2027
Thursday 4^th March 2027