Authorisation for disclosure of medical information relevant to employment
Authorisation for disclosure of medical information relevant to employment
| Name: | Date of birth: | ||
| Address: | |||
| Telephone no: | |||
| To: | |||
| Doctor’s name: | Consultant’s name: | ||
| Address: | Address: | ||
| Telephone no: | Telephone no: | ||
| Hospital reference no: | |||
| Signature: | Dated: | ||
| I hereby consent to a medical report being supplied in confidence to my employer.
I understand my rights under the Access to Medical Reports Act 1988 and have read the summary of my principal rights under the Act attached to this form.
I do/do not wish to have access to the medical report before it is supplied. |
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| Signature: | Dated: | ||