Consent to proxy access to GP Online Services

To complete this form the patient allowing proxy access to their record will need to present in person to the surgery with proof of ID (Photo ID or proof of residence)

Last Updated: 22/09/2020

Section 1

I give permission to my GP practice to give the following people proxy access to the online services as indicated below in section 2.

Full Name *

Named proxies *

The representatives

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

Person 1

Full Name

Date of Birth

Relationship to patient

Address and postcode

Home Telephone

Mobile Telephone

Person 2

Full Name

Date of birth

Relationship to patient

Address and postcode

Home Telephone

Mobile Telephone

Section 3

I/we (the above named representatives) wish to have online access to the services ticked in the box above in section 2 for the above named patient.

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 agree that I will treat the patient information as confidential

I/we will be responsible for the security of the information that 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 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

Signature person 1

Signature person 2

Date

Section 2

Online services to allow access to

Online appointments booking

Online prescription management

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

The patient

(This is the person whose records are being accessed)

Full Name *

Date of Birth *

Address and postcode *

Home telephone number

Mobile phone number

Email Address *

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Consent to proxy access to GP Online Services

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