Patient consent form for detailed coded record access

Do you currently have patient access to online services? Required

Yes

No

Please Register for Online Services before finishing this form.

Who are you completing this form for?

For example, on behalf of a child or dependent

Yourself

Someone else

What is your name?

First name

Last name

What is your date of birth?

For example, 31 3 1980

Day

Month

Year

What is your sex?

As recorded on your medical record

Male

Female

Other

What is your postcode?

The one used to register with your GP

What is your phone number?

What is your email address?

Anyone else with access to your email account may see responses sent to you

Address (include postcode):

NHS Number:

Declaration

Confirmation

I agree to Wargrave Surgery giving me access to my coded record online

Confirmation

I have been provided with an information leaflet which I have read and understood

Confirmation

I agree to use the online system in a responsible manner in accordance with all instructions, and understand that access may be withdrawn

Confirmation

If I see information that does not relate to me, I will immediately log out and report the matter to the Surgery as soon as possible

Confirmation

I agree that it is my responsibility to keep my username and password secure. I am also responsible for keeping safe any information I might print from the coded record

Other Considerations

Wargrave Surgery makes every effort to record information as accurately as possible, however there may be information that you do not feel is correct.

If I notice any inaccuracies, errors or omissions with my coded record, I will put them in writing addressed to my GP as soon as possible.

I understand that I may see information on my record that I was unaware of or have forgotten about that could cause me some distress.

I understand that as before, I will be informed directly by my surgery of any test results which require further action. However I understand that I may see these results, which need further action before the surgery has been able to contact me.

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Patient consent form for detailed coded record access

Declaration

Other Considerations

For staff use only