Register for Online Proxy Access

This form is for parents, guardians and carers requesting 3rd party access to another patients online medical records.

Last Updated: 11/02/2022

Proxy Online Access To Medical Records - Consent Form

Proxy access will allow you to book appointments, order repeat prescriptions, and have access to the elements of the medical record that have been released for online access.

The parent, guardian or carer must show proof of ID and proof of right (birth certificate, adoption certificate/ power of attorney etc) at the time of requesting proxy access.

If there are any limitations on access to the patient or their information imposed by Court or Social Services it must be declared

Confidentiality and Young people

When the patient turns 12 proxy access will be reviewed and consent from them will be required. When turning 16 proxy access will be removed and direct access granted to the patient.

In certain situations it may be appropriate for proxy access to be maintained after the patient turns 16. This will be discussed and approved on an individual basis..

I UNDERSTAND AND AGREE WITH EACH OF THE FOLLOWING STATEMENTS *

I have read and understood the information provided by the practice (via below link) and agree that I will treat the patient information as confidential

I will contact the practice as soon as possible if I suspect that the account has been accessed by someone without my agreement

I will be responsible for the security of the information that I see or download

If I see information in the record that is not about the patient, or is inaccurate, I will contact the practice as soon as possible. I will treat any information which is not about the patient as being strictly confidential

Patient Details

Please fill out the deatils of the person who's medical records are being accessed

Full Name *

Date of Birth *

Full Address *

Post Code *

Phone Number

Email Address

Representative's Details

Please fill out the deatils of the representative who wishes to have proxy access

Full Name *

RELATIONSHIP TO PATIENT *

Date of Birth *

Full Address *

Email Address *

Phone number *

What is the reason for requesting proxy access?

Documents Required

Once we have received your application we will contact you to provide the following documents.

- Photo ID of the representative (Passport, driving liecnce etc.)

- Proof of right to access (Birth certificate, adoption certificate, power of attorney etc.)

Do you have these documents? *

Yes No

This form is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.

Cookies on the Park End Surgery website

Register for Online Proxy Access

Further Information