Online access for proxy

Section 1 – Patient Details

(This is the person whose records are being accessed)

Surname: *

Forename: *

Date of Birth: *

Preferred Contact Number: *

Additional Contact Number:

Email address: *

All responses we send will go to this email address.

Address including postcode: *

Please confirm the folllowing: *

The patient has the capacity to consent to grant proxy access.

The patient does not have the capacity to consent to grant proxy access and proxy access is considered by the practice to be in the patient’s best interest.

I give permission to my GP practice to give the people listed in Section 3 proxy access to the online services as indicated below in Section 2.

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:

Section 2 – Details of access required

Please tick proxy access required:

Online appointment booking

Online prescription ordering

Accessing details coded medical record

Section 3 – Details of the representative(s) seeking proxy access

(These are the people seeking proxy access to the patient’s online records, appointments or repeat prescription)

Representative 1 Surname: *

Representative 1 Forename(s): *

Representative 1 Date of Birth: *

Relationship to patient: *

Preferred Contact Number: *

Additional Contact Number:

Email address: *

Address including postcode: *

Representative 2 Surname:

Representative 2 Forename(s):

Representative 2 Date of Birth:

Relationship to patient:

Preferred Contact Number:

Additional Contact Number:

Email address:

Address including postcode:

I/we wish to have online access to the services ticked above in Section 2 for the patient named in Section 1.

I/we understand my/our responsibility for safeguarding sensitive medical information and I/we understand and agree with each of the following statements: *

I/we have read and understood the information leaflet provided by the Practice and agreed that I will treat the patient information as confidential.

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

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

If I/we see any information in the record that is not about the patient, or is inaccurate, I/we will contact the Practice as soon as possible. I will treat any information which is not about the patient as being strictly confidential.

Your signature(s) *

Representative 1

Date

Your signature(s)

Representative 2

Date

Tell us whether you accept cookies

Section 1 – Patient Details

Section 2 – Details of access required

Section 3 – Details of the representative(s) seeking proxy access