Child (11 to 15) 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:

Please select the access required:

Patient requesting access to their own online services

Proxy requesting access to the patients online services

Section 2 – Terms and Conditions

I have read and understood and accept the following terms and conditions:

I wish to manage all areas of my medical record (book/cancel appointments, request my repeat medication, view allergies and medication in my care records, alter my personal details within my records) myself.

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.

I understand that it is my responsibility to keep my account secure by keeping my details confidential.

I understand that I can terminate my account at any time by contacting the surgery, or change my log in details by re-registering and that this form will be kept on my electronic records.

I understand that my registration will be revoked if I constantly miss or cancel appointments.

I understand that access relies on my parent/guardian/carer providing their signature.

Section 2 – Details of access required

Please confirm the folllowing:

The patient has the capacity to consent to grant proxy access.

The patient does not have the capacity to consent to grant proxy access and proxy access is considered by the practice to be in the patient’s best interest.

I give consent for the parent/guardian/carer named below in section 3 to use online access on my behalf to:

Book/cancel appointments for me

Request my repeat medication

View allergies and medication in my care records

Alter my personal details within my records

Signature of Patient:

Date:

Section 3 – 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 16 and a new consent form will be required when moving into a new age bracket (16 and over).

Signature of parent/guardian/carer:

Date

Identification