Proxy Access Patient Consent Form The Patient (The person whose records another individual(s) is to be given access to)Name First Last Date of Birth Day Month Year Gender Male Female Address Street Address Address Line 2 City Postcode Phone NumberEmail Patient Consent I confirm that I give permission for the Practice to communicate with the person identified above in regards to my medical records. I understand the risks of allowing someone else to have access to my health records. I reserve the right to reverse any decision I make in granting proxy access at any time. The patient is a child under 11 Please select online services you want to grant access to proxy user Online appointments booking Online prescription management Accessing the medical record Select AllYou can restrict access to certain services for proxy user like booking appointments online or managing repeat prescriptions only to protect your privacy.Patient Signature (If request is for child under 11, please leave this blank.) OptionalPlease enter your full name as registered in the practiceToday's Date Day Month Year Details of person to be given access to this patient’s informationName First Last Address Street Address Address Line 2 City Postcode Phone NumberEmail Relationship to PatientProxy User SignaturePlease enter your full nameToday's Date Day Month Year Please upload photo ID (person requesting proxy access)Max. file size: 50 MB.For children up to 16 years old, please upload your child's birth certificate OptionalMax. file size: 50 MB.For adult proxy access, please also upload photo ID for the patient. OptionalMax. file size: 50 MB.Please upload a picture of yourself (person requesting proxy access) holding a piece of paper with today's dateMax. file size: 50 MB.This is to verify that you are who you say you are and the request is current.Consent I/we have read and understood the information leaflet provided by the practice and agree that I 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 practice as soon as possible. I will treat any information which is not about the patient as being strictly confidential Name OptionalThis field is for validation purposes and should be left unchanged.
