Proxy Access to Medical Records (Child) Proxy Access to Medical Records (Child) Cared for Patient’s DetailsThis form is specifically for children living at a different address to the parent/carer requesting access, or where the parent/carer is not a registered patient at Wellspring SurgeryFull Name Date of Birth DD slash MM slash YYYY AddressParent / 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 Optional Mrs Optional Miss Optional Ms Optional Dr Optional Other Optional Gender Male Female Other Date of Birth DD slash MM slash YYYY AddressRegistered At Wellspring Surgery Other Email Address Consent to Email Registration Details Optionalif registered at another practiceRelationship to child above Mother Optional Father Optional Carer Optional Other Family Member Optional Signature of Parent/CarerReset to re-sign.Date DD slash MM slash YYYY Book/cancel appointments Request repeat medication View the core medical record (medication & allergies) View immunisations information 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.This 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.
