Consent to proxy access to GP online services

This is for the person whose records are being accessed.

Address (including postcode): *

Section 1

I, the patient, give permission to my GP practice to give the representatives stated on this form, 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 record.

I have read and understood the information leaflet provided by the practice.

Signature: *

Date:

Section 2

The representatives stated on this form, are allowed proxy access to the following services:

Online appointments booking

Online prescription management

Accessing the medical record for the patient

Section 3

I/We, the representatives, wish to have online access to the services ticked in the box above in section 2 for the patient of this form.

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/we will treat any information which is not about the patient as being strictly confidential.

Signature: *

Date:

Representative

This is for the people seeking proxy access to the patient's online records, appointments or repeat prescription.

Surname: *

First Name: *

Date of Birth: *

Address (including postcode): *

Email Address: *

Home Telephone Number: *

Mobile Phone Number: *

For Practice Use Only - Patient Details

Method:

Vouching

Vouching and information in record

Photo ID and proof of residence

Consent to proxy access to GP online services