Consent Form B - ADHD & Autism Clinic

Allow others to share my information with The ADHD and Autism Clinic

Name(Required)

First Last

Address(Required)

First line of address Address Line 2 City Postcode

Date of birth(Required)

dd/mm/yyyy

Mobile number(Required)

List the name of the person(s)/organisation(s) with whom you give consent to share the requested information.(Required)

Insert name and address of third-party (e.g. your GP surgery, your NHS psychiatrist, your employer etc)

Is there any information that you do not wish to share?

For example, you may be willing for information about your treatment to be shared, but you may not wish information about your personal history to be shared.

Yes

If (yes) please provide the information below