Belmont Medical Centre - Consent to proxy access to GP online services

Belmont Medical Centre
18 Western Road
Southall UB2 5DU
Tel: 0208 893 5515
Consent to proxy access to GP online services
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.

Note: This form applies to everyone outside of the 13-16 age bracket. Please contact the practice if the patient is within this age range.
Section 1
I (Answer 1), give permission to my GP practice to give the following people

(Answer 2) proxy access to the online services as indicated below in section 2.
Answer 1 - Name of patient

First NameSurname
Answer 2 - Names of representatives

First NameSurname
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
Signature of patient

Clear
Date

DayMonthYear
Date
Section 2
1. Online appointments booking2. Online prescription management3. Access to detailed coded record
Section 3
I/we understand and agree with each of the following statements:

1. I/we have read and understood the information leaflet provided by the practice and agree that I will treat the patient information as confidential2. I/we will be responsible for the security of the information that I/we see or download3. 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 agreement4. 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

Consent to proxy access to GP online services

Section 1

Section 2

Section 3

The patient

The representatives