Proxy Access to Medical Records (Adult) Proxy Access to Medical Records (Adult) Cared for Patient's DetailsTo give consent for proxy access to their online services Full Name Date of Birth DD slash MM slash YYYY AddressConsentTo be completed by the person named above unless lacks capacity because of medical condition I give consent for the person named below to have online services access to: Book/cancel appointments for me: Yes No Request my repeat medication Yes No View my core medical record (medication & allergies) Yes No View the immunisations information in my care record: Yes No NO View test results in my care record: Yes No SignatureReset to re-sign.Date DD slash MM slash YYYY Consent OR, Patient lacks capacity to consent because of medical condition OptionalPlease provide copy of legal paperwork (Power of Attorney/Court Appointed Deputy). If paperwork cannot be supplied then GP will need to confirm incapacity before access is given. Parent / Carer Details(Requesting proxy access to online services for the patient named above) We need these details to be able to trace your existing online user accountFamily Name Given Name Title Mr Mrs Miss Ms Dr Other Gender Male Female Other Date of Birth DD slash MM slash YYYY AddressRegistered At Wellspring Surgery Other Email Address Consent Consent to Email Registration Details Optional(if registered at another practice)Relationship to child above: Mother Father Carer Other Family Member Signature of Parent / Carer:Reset to re-sign.Date DD slash MM slash YYYY If you are registered with us, access will be added to your existing Online Services account – you will be able to switch to child/cared for person’s account via Linked Users (in drop-down menu under your name). If you are registered elsewhere, we will email you the registration document you need in order to link your account to our practice patient. Please hand this form to reception – if your request is not actioned within 1 week then please contact usPrivacy Consent I consent to the practice collecting and storing my data from this form. OptionalThis form collects personal and medical information about you. We use this information to allow the practice team to contact you. Please read our Privacy Policy to discover how we protect and manage your submitted data.
