Sharnbrook Surgery - Proxy Consent Form

Consent to proxy access to GP Online Services
Section 1
I,Full name* (name of the patient), give permission to my GP practice to give the following people, Full name* proxy access to the online services as indicated below in section 2.
1. I reserve the right to reverse any decision I make in granting proxy access at any time.
2. I understand the risks of allowing someone else to have access to my health records.
3. I have read and understand the information leaflet provided by the practice
Signature of patient*

Clear
Section 2
Online appointments bookingOnline prescription managementAccessing the medical record for the patient stated in section 1
Section 3
I/we Full name* (names of representatives) wish to have online access to the services ticked in the box above in section 2 for Full name* (name of patient).
I/we understand my/our responsibility for safeguarding sensitive medical information and i/we understand and agree with each of the following statements:
I/we have read and understood the information leaflet provided by the practice and agree that I will treat the patient information as confidentialI/we will be responsible for the security of the information that I/we see or downloadI/we will contact the practiceas soon as possible if I/we suspect that the account has been accessed by someone without my/our agreementIf 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
Signature/s of representative/s

Clear
Section 4
The patient

(This is the person whose records are being accessed)
Name*

First NameLast Name
Date of birth*

DayMonthYear
Date
Address*

Street Address

Street Address Line 2

CityCounty

Postal / Zip Code
Email*
example@example.com
Contact Number*
The representatives

(These are the people seeking proxy access to the patient’s online records, appointments or repeat prescription.)
How many representatives are there?*

12
First representative
Name*

First NameLast Name
Date of birth*

DayMonthYear
Date
Email*
example@example.com
Contact Number*
Address*

Street Address

Street Address Line 2

CityCounty

Post Code
Second representative
Name*

First NameLast Name
Date of birth*

DayMonthYear
Date
Email*
example@example.com
Contact Number*
Address*

Street Address

Street Address Line 2

CityCounty

Post Code
Should be Empty:

Consent to proxy access to GP Online Services

Section 1

Section 2

Section 3

Section 4

The patient

The representatives