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: *

2nd Representative

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 One (Patient to complete, not required for under 11’s)

*

I give permission to my GP practice to give the below individual(s) proxy access to the online services as indicated in section two. 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 having access to my health records.

Signature of Patient: *

Date:

Section Two

Representative/Proxy is authorised access to:

Online appointment booking

Online prescription management

Accessing the medical records of the patient

Section Three

Representative/proxy to complete.

*

I/we wish to have online access to the services ticked in the box above in section two for this patient. I/we understand my/our responsibility for safeguarding sensitive medical information.

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 else without my/our agreement

If I/we see any 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 that is not about the patient as being strictly confidential

Signature(s) of representative(s): *