Consent for a doctor's report form template | Acas

Template for a consent form for an employer to ask for a worker's permission to approach their doctor for health information. Free to use.

You must get permission from the worker before contacting their doctor.

You can copy and paste the template text into an email or document.

Documents

If you need the template in a different format, email digital@acas.org.uk

You can also copy and paste the following template text.

Name:

Address:

Date of birth:

Doctor name:

Doctor address:

I give consent for my employer to get a medical report from my doctor.

☐ Yes

☐ No

I want to see a copy of the report before it is sent to my employer.

☐ Yes

☐ No

I confirm that if I do want to see a copy of the report, I will contact the doctor within 21 days of my employer requesting it.

I confirm I have read and understood my rights under the Medical Records Act 1988.

☐ Yes

☐ No

Signed:

Date:

Last reviewed

20 May 2025