Proxy access patient consent

Patient Details

The person whose records another individual(s) is to be given access to

First Name:

Last Name:

Date of Birth:

For example, 31/03/1980

Gender:

Male

Female

Address (including postcode):

Phone Number:

Email Address:

Patient consent:

I confirm that I give permission for the practice to communicate with the person identified above in regards to my medical records

I understand the risks of allowing someone else to have access to my health records

I reserve the right to reverse any decision I make in granting proxy access at any time

The patient is a child under 11

Please select online services you want to grant access to proxy user:

Online appointments booking

Online prescription management

Accessing the medical record

You can restrict access to certain services for proxy user like booking appointments online or managing repeat prescriptions only to protect your privacy

Patient Signature:

Please enter your full name as registered in the practice. If request is for a child under 11, please leave this blank.

Date:

Details of person to be given access to this patient’s information

First Name:

Last Name:

Address (including postcode):

Phone Number:

Email Address:

Any responses we send will go to this email address

Relationship to patient:

For example, relative, friend, carer

Proxy user signature:

Please enter your full name

Date:

Please upload evidence:

Photo ID for the person requesting proxy access
Child’s birth certificate for children up to 16 years old (optional)
Photo ID for the patient for adult proxy access (optional)
A photo of yourself (person requesting proxy access) holding a piece of paper with today’s date to verify that you are who you say you are and the request is current

Upload a photograph or document

Maximum upload size: 67.11MB

Consent:

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

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Patient Details

Details of person to be given access to this patient’s information