PLEASE USE A TOUCHSCREEN DEVICE TO COMPLETE THIS FORM including SIGNING YOUR SIGNATURE ON THE SCREEN and then SUBMIT

If you do not have a touch screen device or have issues please scroll to the end download the pdf version, complete and scan back to george@tgn.co.nz

Medical Information Consent

I consent to {nameOf26} seeking medical information from any doctor or other medical provider I have consulted, to the extent this is reasonably necessary to evaluate my insurance application, administer any policy that arises from the application, and consider claims against and validity of that policy.

I understand that a third party may also be used to process this information request for {nameOf26}.

I authorise any such doctor or another medical provider to provide such information to {nameOf26}.

I agree that a photocopy of this consent is as valid as the original.

Name of insurance company seeking consent to review my medical information

Title

Family name

Given name(s)

Email

example@example.com

Is registered under (if different from above)

Date of birth

DayMonthYear

Your GP's details

Postal Address

Name of Doctor/ Practice

Phone Number

Area CodePhone Number

Practice street address

Please sign both 'Authorised Signature at Practice' AND 'Person to be insured' below they can be different people sometimes

Authorised Signature at Practice

Date

DayMonthYear

Signature of Person to be Insured

Date

DayMonthYear

If you do not have a touch screen device to fill in the form above or have problems with it, please download this pdf version, fill in, sign and scan back to george@tgn.co.nz