Consent to proxy access to GP Online Services

Information

If, as a parent, you are applying for access to your Childs records, we will need you to confirm your parental rights. If your child is competent and able to understand the implications of your access, then we will need to get their consent first even if they are under 11 years of age.

Section 1

The Patient (To be completed by the child where age permits. This is the person whose records are being accessed)

First Name

Surname

Date of Birth

Address

House Name/ Number

Street

Town

Postcode

Declaration

I give permission to my GP practice to give the following person proxy access to the online services as indicated below in section 3. 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 have access to my health records.

Print Name of Patient (Signature)

Date

Section 2

Online Services

Section 3

The representative (This is the person seeking proxy access to the patients online records, appointments or repeat prescription)

Declaration

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

Print Name of Representative (Signature)

Relationship to the patient

Print Name of patient, required if over 11 years of age (Signature)

Section 4 (The Representative)

This is the person seeking proxy access to the patients online records, appointments or repeat prescription

Representative 1

First Name

Surname

Date of birth

Email Address

Contact Number

Mobile Number Optional

Representative 2 (if apllicable)

First Name Optional

Surname Optional

Date of birth Optional

Email Optional

Contact Number Optional

Mobile Number Optional

Untitled Optional