Authorisation for disclosure of medical information relevant to employment
|Name:||Date of birth:|
|Doctor’s name:||Consultant’s name:|
|Telephone no:||Telephone no:|
|Hospital reference no:|
|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.