Child (10 and under) consent to proxy access to GP online services

Section 1 – Patient Details

(This is the person whose records are being accessed)

Surname: *

Forename: *

Date of Birth: *

Preferred Contact Number: *

Additional Contact Number:

Email address: *

All responses we send will go to this email address.

Address including postcode:

Section 2 – Details of the representative seeking proxy access

(This is the parent/guardian/carer seeking proxy access to the patient’s online records, appointments and repeat prescription)

Representative Surname: *

Representative Forename(s): *

Representative Date of Birth: *

Relationship to patient: *

Preferred Contact Number: *

Additional Contact Number:

Email address: *

Address including postcode: *

I wish to have online access on behalf of the child named above in Section 1.

I understand my responsibility for safeguarding sensitive medical information and I understand and agree with each of the following statements:

I have read and understood and agree to abide by the terms and conditions for online access as kept on www.support.patientaccess.com/terms-of-use if access is granted to you and agree that I will treat the patient information as confidential.

I will be responsible for the security of the information that I suspect that the account has been accessed by someone without my agreement.

I will contact the practice as soon as possible if I suspect that the account has been accessed by someone without my agreement.

If I see information in the record that is not about the patient or in inaccurate I will contact the practice as soon as possible. I will treat any information which is not about the patient as being strictly confidential.

Parent/guardian/carer access will be removed when the child turns 11 and a new consent form will be required when moving into a new age bracket (11 to 15 or 16 and over).

Your signature:

Representative

Date

Proof of Identification

You must now come into the surgery with 2 forms of identification for the patient and the proxy. We cannot grant proxy access until we have seen this ID.

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Child (10 and under) consent to proxy access to GP online services

Section 1 – Patient Details

Section 2 – Details of the representative seeking proxy access

Proof of Identification