Form - Consent to Proxy Access to GP Online Services

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Application for Online Access

Consent to proxy access to GP online services

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.

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All questions marked with a * are mandatory

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  • Patients under the age of 16 cannot have their own account
  • Patients over the age of 16 must have their own personal email account which cannot be shared
I am: *
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Details of the Patient

(This is the person whose records are being accessed)

Please double check you've entered the correct email address
I wish to have access to the following online services: *
The Representatives
 

If you are making an application on the behalf of somebody else we require evidence of your Authority

Please upload a copy your supporting documents

  • You can upload a document, photo or scan

We require evidence of your Authority or Birth Certificate

Please upload a copy your supporting documents

  • You can upload a document, photo or scan
Only following file extensions are allowed: jpg, jpeg, png, webp, pdf, doc, docx, pptx
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Proof of Identity
NHS Logo

Identification

We are required to check the identity of all applicants

Acceptable forms of Photo ID

  • Photo Driving License
  • Passport

ID documents are not stored and will be securely destroyed in line with our data retention schedule.

Acceptable forms of Proof of Residence

  • Tenancy agreement
  • Mortgage statement
  • Bank statement
  • Utility bill (date within the past 3 months) 

Please upload a copy of 's ID and Proof of Address

  • You can upload a document, photo or scan
Please upload a copy of your ID and Proof of Address
  • You can upload a document, photo or scan
Only following file extensions are allowed: jpg, jpeg, png, webp, pdf, doc, docx, pptx
Only following file extensions are allowed: jpg, jpeg, png, webp, pdf, doc, docx, pptx

Please upload a copy of 's ID and Proof of Address

  • You can upload a document, photo or scan
Only following file extensions are allowed: jpg, jpeg, png, webp, pdf, doc, docx, pptx
Only following file extensions are allowed: jpg, jpeg, png, webp, pdf, doc, docx, pptx

Please upload a copy of  's ID and Proof of Address

  • You can upload a document, photo or scan
Only following file extensions are allowed: jpg, jpeg, png, webp, pdf, doc, docx, pptx
Only following file extensions are allowed: jpg, jpeg, png, webp, pdf, doc, docx, pptx
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To be completed by the Patient

I, , give permission to my GP practice to give the following people proxy access

    

Proxy access will be given to the following online services

  • Booking appointments: %%form-element-5145%%
  • Requesting repeat prescriptions: 
  • Access to my medical records: %%form-element-5147%%
  • Access to test results: %%form-element-5148%%
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: *
Patients requiring access to their own record
I have read and understood the information provided by the practice on the previous pages: *
I will be responsible for the security of the information that I see or download: *
If I choose to share my information with anyone else, this is at my own risk: *
I will contact the practice as soon as possible if I suspect that my account has been accessed by someone without my agreement.: *
If I see information in my record that is not about me or is inaccurate I will contact the practice as soon as possible.: *
Proxy declaration

 , as the lead applicant agree the following and sign.

I/We have read and understood the information provided by the organisation and agree that I/we 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 organisation as soon as possible. I/we will treat any information which is not about the patient as being strictly confidential: *
I/We declare that the information given by me is correct to the best of my knowledge and that I am entitled to apply for access to the health records referred to above under the terms of the Data Protection Act 2018.: *
I/We understand that the making of false or misleading statements in order to obtain personal information to which you are not entitled is a criminal offence which could lead to prosecution.: *
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Privacy Consent

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