Consent to proxy access to GP online services

Please confirm the following:

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.

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. Please use representative email address if the patient does not have capacity.

Address including postcode:

Section 1 continued – Patient signature

I, the patient, give permission to my GP practice to give the following people proxy access to the online services as indicated below.

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 understand the information leaflet provided by the practice.

Signature of Patient:

Date:

Section 2 – Details of access required

Please tick proxy access required:

Online prescription management

Accessing full medical record for patient

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.

Representative signature/s

Your signature(s)

Representative 1

Date

Your signature(s)

Representative 2

Date

File upload

In order to complete this form, you will need to upload or hand in proof of ID to reception:

Maximum file size: 67.11MB

This can be ID such as a current signed passport, original birth certificate or current UK or EEA photocard driving licence.

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Section 1 – Patient Details

Section 1 continued – Patient signature

Section 2 – Details of access required

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

Representative signature/s

File upload