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

* 

*

*