Register for GP Online Services – Child aged 11-15

Child Details

Contact number

Please indicate the email address that any responses to this request should be sent to:

Children aged 11-15 can:

– Access their own GP services online

– Allow a parent/carer/guardian access to some or all services (proxy access)

– Allow a combination of 1 and 2

The child’s GP may need to discuss online access with him/her and/or any proxy applying for access on the child’s behalf

– I will be responsible for the security of the information that I see or download

– If I choose to share information with anyone else, this is at my own risk

– I will contact the practice as soon as possible if I suspect that this account has been accessed by someone without my agreement

– If I see information in the record that is not about me, or inaccurate, I will contact the practice as soon as possible

Signature (of child)

– 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 proxy access to my health records, should I have authorised this

Signature

If the child is unable to provide informed consent to proxy access, please indicate why: Optional

– I will be responsible for the security of the information that I see or download

– If I choose to share information with anyone else, this is at my own risk

– I will contact the practice as soon as possible if I suspect that this account has been accessed by someone without my agreement

– If I see information in the record that is not about the patient or inaccurate, I will contact the practice as soon as possible

Contact number

Relationship to child:

Signature

If you would like to add another user, please contact reception.