Application Medical Authority Form for Residence

This Medical Authority is required as part of your application for registration as an Applicant for Residence in a single or double flat at Abbot's Hospital.

Please read the Application Process and Residence Requirements notes, BEFORE completing the Application Medical Authority Form below.

Medical Authority Form for Abbot's Hospital Residence Application

Abbot’s Hospital, High Street Guildford Surrey GU1 3AJ
The Hospital of the Blessed Trinity - Registered charity no. 201631

Name

Date of Birth (dd/mm/yyyy)

Address

Postcode

Email

Your Current GP's Name

Address of GP's Surgery (please include postcode)

AUTHORISATION:

I hereby authorise:
1) The medical practice of my GP to give to the Hospital’s Honorary Physician such details of my medical history as he may request.
2) The Hospital’s Honorary Physician to pass on to the Master the results of any medical examination and such details of my medical history as he may think appropriate.
3) The Master to pass on any relevant details:
a) to Governors of Abbot’s Hospital to help them determine any application by me, and
b) to Hospital staff, emergency call services and NHS staff, to help me in the event of an emergency.
I understand that this information will be used only in connection with my application for residence at Abbot’s Hospital, Guildford, and for my subsequent care if I am appointed as a resident.

Authorisation Signed By - Name:

Date Authorisation Signed (dd/mm/yyyy):

Human test: Which is bigger, 2 or 8?