ࡱ> RTQ bjbj arrK x        8Xl ~.$^# "#  %8iiiF  iiii?+^iN0~i(j(ii( }li##v~( :  PLEASE USE A BLACK PEN CONSENT TO ACCESS MEDICAL INFORMATION AND SHARING OF DATA Child/Young Person.......DOB Address I,Parent/Guardian/Young Person hereby give my consent for a representative from Chestnut Tree House to access the medical records on behalf of my son/daughter . This will assist them in gaining information to help process the referral. I/We have consented to be referred to their services. I understand that no information can be accessed without my written consent. I confirm that I have also received a copy of the Family Information Leaflet Personal Information and How We Use It and understand the contents and implications of the information contained therein. Signed . Date .. Parent/Guardian/Young Person Signed . Date .. 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