Consent Form 

Patients Name:…………………………………………………………………………..………
Patients Address:
………………………………………………………………………………………………………
………………………………………………………………………………………………………
…………………………………………………………….......................................................
Date of Birth:………………………………………………………………………………………

I give my consent for Kings College Health Centre to give copies/information of my medical notes to:…………………………………………….…………………………………...

Handwritten Signature:…………………………………………………………………….…….
Date:………………………………………………………………………………………………..