Consent to proxy access to GP online services

Patient Details

This is the person whose records are being accessed

First Name: *

Surname: *

Address, including postcode: *

Email Address:

Telephone Number:

Mobile Number:

Representative Details

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

First Name: *

Surname: *

Address, including postcode: *

Telephone Number: *

Mobile Number: *

First Name:

Surname:

Address, including postcode:

Email Address:

Telephone Number:

Mobile Number:

Does the patient have capacity to consent to grant proxy access? Where the patient is incapable, proxy access will be given by the practice if it is considered to be in the patient’s best interest. *

Yes

No

Section 1

I, the patient, give permission to my GP practice for the representatives (entered below) to have proxy access to the online services as indicated in Section 2.

I reserve the right to reverse any decision I make in granting 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 Online Access for Patients – Important Information.

Signature: *

Date:

Section 2

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

Booking appointments

Requesting repeat prescriptions

Accessing elements of the patient’s medical record with the agreement of their GP

Section 3

I/we, the representative(s), wish to have online access to the services selected in Section 2 on behalf of the 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 Online Access for Patients – Important Information 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 my/our account has been accessed by someone without my agreement.

If I/we see information in my record that is not about me 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(s) of representative(s): *