Proxy Access to GP Online Services Facebook OptionalThis field is for validation purposes and should be left unchanged.I,(patient) give permission for The Village Practice to allow the following person/s(representative)proxy access to the online services ticked below.Online Services Booking Appointments Requesting Prescriptions Access to My Online Medical Records Consent I understand I reserve the right to reverse any decision I make regarding proxy access I understand the risks of allowing someone else to have access to my health records I have read and understood the information leaflet provided by the practice.Patient Signature:Date DD slash MM slash YYYY If the patient does not have the capacity to consent to grant proxy access and proxy access is the patient’s best interest, then Section 1 of this form can be signed by the patient’s named GP.I,(name of representative), wish to have online access to the services ticked above for(patient)I understand and agree with the following statements: I understand my responsibility for safeguarding sensitive medical information. I have read and understood the leaflet provided by the practice and agree to treat all the patient information as confidential. I will be responsible for the security of the information I see or download. I will contact the Practice as soon as possible if I suspect the account has been accessed by someone who does not have proxy access. If I see information in the record that is not about the patient or inaccurate, I will contact the practice as soon as possible. I will treat any information that is not about the patient as strictly confidential Representative Signature:Date DD slash MM slash YYYY Patient identification Drop files here or Select files Max. file size: 1 GB. Proxy identification Drop files here or Select files Max. file size: 1 GB. The Patient’s DetailsName Dr.MissMr.Mrs.Ms.Mx.Prof.Rev. Title First Last Former Name OptionalEmail PhoneAddress Street Address Address Line 2 City Postcode The Representative’s DetailsThe representative must produce photo ID/child’s birth certificate/ red child health book if registering on behalf of a childName Dr.MissMr.Mrs.Ms.Mx.Prof.Rev. Title First Last Former Name OptionalPhoneEmail Address Street Address Address Line 2 City Postcode
