Consent to Proxy Access to GP Online Services

Last Updated: 22/12/2023

Consent to Proxy Access

If the patient does not have capacity to consent to grant proxy access and proxy access is considered by the practice GP to be in the patient's best interest, this section may be omitted.

Name of patient giving permission to GP practice to give proxy access to online services.

Name of persons being given proxy access

I confirm that I give permission to my GP practice for the above name persons to have proxy access to online services. 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. I have read and understand the information leaflet provided by the practice.

Yes No

Today's Date

The Patient

This is the person whose records are being accessed

Full Name *

Date of Birth *

Age *

Address including postcode *

Email address

Home Telephone Number *

Mobile Telephone Number

Representatives

Please give details of the representative(s) wishing to have online access to the services requested in the Permission Section.

Name of Representative(s) *

Relationship to Patient *

I/We understand my/our responsibility for safeguarding sensitive medical information. *

Yes No

I/we have read and understood the information leaflet provided by the practice and agree that i/we will treat the patient information as confidential. *

Yes No

I/we will be responsible for the security of the information that I/we see or download. *

Yes No

If I/we see 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 which is not about the patient as being strictly confidential. *

Yes No

Permission

I give permission for my representatives named in this form to be given access to the following: *

Online appointments booking

Online prescription management

Limited access to parts of my medical record

The Representatives

These are the people seeking access to the patient's online records, appointments or repeat prescriptions.

Full Name of First Representative *

Date of Birth *

Address including postcode *

Email address *

Home Telephone Number *

Mobile Telephone Number *

Full Name of Second Representative (if any)

Date of Birth

Address including postcode

Email address

Home Telephone Number

Mobile Telephone Number

Electronic Submission

This form cannot be processed without identification being provided for each person named above.

Please confirm you have sent copies of each person's identification to: medical.reports@nhs.net - your application will not be processed without identification. *

Yes No

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Consent to Proxy Access to GP Online Services

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