Consent Form To Release Occupational Health Report

Please Only Tick One Box*
- I give consent for the occupational health report to be released without prior viewing. I do not require a copy to be sent to my home address.
- I give consent for the occupational health report to be released without prior viewing. I would like a copy to be sent to my home address.
- I would like to view the occupational health report before it is released to my employer. I am aware that if I choose to respond to the contents of the report, I have up to 48 hours upon receipt by email to do so. I have up to 5 working days to respond and for it to be returned if the report is posted to me. If no response is received within the stipulated timescales, I am aware that the report will be released. I am also aware that the doctor can only amend factual inaccuracies and not opinions. If the doctor is unable to amend the report, I consent for the report to be released to my employer with my comments attached to it.
Please Only Tick One Box*
- Send Report By Email To (Provide Email Address)
- Send Report By Post To (Provide Mailing Address):
- I do not consent for the occupational health report to be released.
Name*
Title First Name Last Name
Patient Signature*
First
Today's Date*

Day
Month
Year

Authorisation For The Release Of Medical Information
Surname*
Forenames*
Date of Birth*

Day
Month
Year
Home address*
Street Address City State / Province / Region ZIP / Postal Code Country
Telephone No.*

Signature of Authorisation
- I consent to a medical report from my doctor/specialist being supplied to The London General Practice.
- I consent to medical reports from my doctor/specialist being supplied to my employer.
Employee’s signature*
First
Today's Date*

Day
Month
Year

Authorisation For The Release Of Medical Information