Consent for the release of patient results 

Please copy and paste the required details listed below into an email and send to nvrl.admin@healthmail.ie

-----------------------------------------------------------------------------------------------------------------------

Consent for the release of patient results

NB: This is used for the release of results to a clinician OTHER than the original requesting clinician

Requested by___________________________

Contact number _________________________

Patient details:

Forename_______________________

Surname________________________

Date of Birth_____________________ 

Patient address

___________________________________________

___________________________________________

Year testing occurred__________________________

Original Hospital/Practice/Clinic name_____________________________

Test results required: 

__________________________________________________________________

___________________________________________________________________

Clinician Name (name of Dr to whom results will be posted)_________________________

Postal address for copy results

___________________________________________________________

___________________________________________________________