Proxy access to GP online services

Patient Details

This is the person whose records are being accessed

First Name: *

Surname: *

Address:

Postcode:

Telephone Number:

Mobile Number:

Doctor:

Does the patient have the capacity to grant proxy access? *

Yes

No

Patient Consent

I have read and understood the following conditions: *

I give permission to my GP practice to give my representatives (named below) proxy access to the online services indicated

I reserve the right to reverse any decision I make in granting proxy access at any time.

I understand the risks of allowing someone else to have access to my health records.

I have read and understood the information leaflet provided by the practice.

Signature of patient: *

Date:

Representatives

These are the people seeking proxy access to the patient’s online records, appointments or prescriptions

First Name: *

Surname: *

Relationship to the patient: *

Phone Number: *

Address:

Postcode:

First Name:

Surname:

Relationship to the patient: *

Phone Number:

Address:

Postcode:

*

I/we the representatives wish to have online access to the services selected below on behalf of the patient

I/we wish to have access to the following online services (Please select all that apply):

Booking Appointments

Requesting repeat prescriptions

Accessing my medical record

*Please allow two working days for your electronic access to be activated.

Please note you will need to verify your identity with two forms of identification, one must contain a photo and one must contain address details. Acceptable documents include passports, photo driving licenses and bank statements, utility bills (not mobile telephone bills).

If you need any further information or assistance with this matter, please ask at reception.

Application for online access to my medical record

I/we wish to have access to the patient’s medical record and have read and understand the following: *

I/we agree to the GP Practice giving access to the record online

I/we will be responsible for the security of the information that I/we see or download.

If I/we choose to share information with anyone else, this will be at our own risk.

I/we will contact the practice as soon as possible if I/we suspect that someone without our agreement has accessed the account.

If I/we see information in my record that is not about the patient, or is inaccurate I/we will log out immediately and contact the practice as soon as possible.

I/we understand that I/we may see information on the record that I/we was unaware of/have forgotten about that could cause distress.

I/we understand that as before, I/we will be informed directly, by the practice, of any test results that require further action. However I/we understand that I/we may see these results online before the practice has been able to contact us. This could be while the surgery is closed and there is no one available to discuss them with us.

Signature of representative: *

Signature of representative:

Date:

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Patient Details

Patient Consent

Representatives

Application for online access to my medical record