Consent to proxy access to GP Online Services

Parental/ Carer access

Information

If, as a parent, you are applying for access to your Childs records, we will need you to confirm your parental rights. If your child is competent and able to understand the implications of your access, then we will need to get their consent first even if they are under 11 years of age.

Section 1

The Patient (To be completed by the child where age permits. This is the person whose records are being accessed)

Address

Declaration

I give permission to my GP practice to give the following person proxy access to the online services as indicated below in section 3. 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.

Section 2

Online Services
Tick all that apply

Section 3

The representative (This is the person seeking proxy access to the patients online records, appointments or repeat prescription)
I confirm that i am wishing to have online access to the services ticked in the box above in section 2

Declaration

I understand my responsibility for safeguarding sensitive medical information and understand and agree with each of the following:
Please tick all that apply
Please tick the most relevant statement
Proof may be required to indicate that parental rights have not been removed by the courts.

Section 4 (The Representative)

This is the person seeking proxy access to the patients online records, appointments or repeat prescription

Representative 1

Address

Representative 2 (if apllicable)

Address
Address