Consent to Proxy Access to GP Online Services This form will need to be competed by both the Patient and the Representative/s (person/s you are giving proxy access) Note: If the patient does not have capacity to consent to grant proxy access and proxy access is considered by the practice to be in the patient’s best interest section 1 of this form may be omitted.Section 1I consent to give permission to my GP practice to give the following people that I will name below in section 4b proxy access to the online services as indicated below in section 2. 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 Sign: Full Name of Patient Date Day Month Year Section 2Access: Online appointments booking Online prescription management Accessing the medical record for patient Section 3I/we (representatives) wish to have online access to the services ticked in the box above in section 2 for named patient. I/we understand my/our responsibility for safeguarding sensitive medical information and I/we understand and agree with each of the following statements:Declaration I/we have read and understood the information leaflet provided by the practice and agree that I will treat the patient information as confidential I/we will be responsible for the security of the information that I/we see or download I/we will contact the practice as soon as possible if I/we suspect that the account has been accessed by someone without my/our agreement 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 will treat any information which is not about the patient as being strictly confidential Section 4a – The patient (This is the person whose records are being accessed)Surname First Name Date of Birth Day Month Year Address Street Address Address Line 2 City Postcode Email Enter Email Confirm Email Telephone Contact NumberSection 4b – The representatives (These are the people seeking proxy access to the patient’s online records, appointments or repeat prescription.)Surname First Name Date of Birth Day Month Year Email Enter Email Confirm Email Telephone Contact NumberWould you like to add another Representative? Yes No Surname First Name Date of Birth Day Month Year Email Enter Email Confirm Email Telephone Contact NumberUpload the ID of the patient OptionalMax. file size: 1 GB.Upload the ID of the representative OptionalMax. file size: 1 GB.
