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Proxy Access Online Services Form

Note: If the patient does not have 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 of this form may be omitted.

For verification purposes, to complete your registration you will need to attach two forms of identification to the form below. One form of photo ID (passport, driving licence) and one form of proof of address (utility bill, bank statement).

Proxy Access Form

This field is for validation purposes and should be left unchanged.
Section 1 (to be completed by the patient) I give permission to my GP practice to give proxy access to the online services (as indicated below in Section 2) to the individuals named below(Required)
Name of individual to receive access(Required)
I reserve the right to reverse any decision I make in granting proxy access at any time.(Required)
I understand the risks of allowing someone else to have access to my health records(Required)
I have read and understand the online access patient information above provided by the practice.(Required)
Date(Required)
Section 2 (to be completed by the patient) I wish to have access to:(Required)
Please be aware that some of the above services may not be available.
Section 3 (to be completed by the representatives) I/we wish to have online access to the services ticked in the box above in Section 2 for the patient in Section 4.(Required)
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 online access patient information above provided by the practice and agree that I/we will treat the patient information as confidential(Required)
I/we will be responsible for the security of the information that I/we see or download(Required)
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(Required)
If I/we see information in the record that is not about the patient, or is inaccurate, I/we will contact the practice as soon as possible. I/we will treat any information which is not about the patient as being strictly confidential(Required)
Section 4 The Patient – (This is the person whose records are being accessed)(Required)
Date of birth(Required)
Address(Required)
Drop files here or
Max. file size: 128 MB, Max. files: 2.
    Privacy Notice This form collects your name, date of birth, email, other personal information and medical details. This is to confirm you are registered with the practice, to allow the practice team to contact you and also to update your medical records held by the practice and our partners in the NHS. Please read our Privacy Notice to discover how we protect and manage your submitted data(Required)

     

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