Patient consent form for detailed coded record access

Do you currently have patient access to online services? *

Yes

No

Please Register for Online Services before finishing this form.

Section

Address (include postcode):

NHS Number:

Declaration

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

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

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to use the online system in a responsible manner in accordance with all instructions, and understand that access may be withdrawn

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

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.

For staff use only

Photographic proof received and verified

Contact details checked and updated if necessary

Over 16 years of age – or a parent or carer

GP Authorised:

Date: