Consent to Proxy Online Access Registration

Section 1

Patients Name

I the patient give permission to my GP practice to give the following people named below in section 5 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 records.

I have read and understand the information leaflet

Signature of patient (Full Name)

Date

Section 2

Please tick:

Online appointments booking

Online prescription management

Accessing the medical record for……(Give patients name below)

Patients Name

Section 3

I/we wish to have online access to the services ticked in the box above in section 2 for the named patient. I/we understand it is my/our responsibility for safeguarding sensitive medical information and I/we understand and agree with each of the following statements:

Please tick:

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

Signatures of representative/s (Full Name)

Date

Phone

Section 4 – The Patient

Full Name

Date of Birth

Address

Postcode

City

Country

Email

Confirm Email

Telephone Number

Mobile Number

Section 5 – The representatives

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