eMR Consent Form

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eMR Consent Form (SAR Request - Authorising Amersham Vale Practice to share with medi2data/eMR)
Personal Details
 
UK mobiles only
Patient Consent

Please chose one of the following options below:

please specify the exact dates (from date to to date) you want your SAR to include

All the below options need to be ticked to authorise us to submit a SAR request on your behalf

 
 

Privacy Consent

This form collects personal and medical information about you. We use this information to allow the practice team to contact you. Please read our Privacy Policy to discover how we protect and manage your submitted data.

 
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