Register for online proxy access to medical record (children under 12 and carers)

Details of Patient

Surname: *

First Name: *

Date of Birth: *

Please use this date format: DD/MM/YYYY

Address and Postcode: *

Is the patient under 12 years old? *

Yes

No

Details of Applicant

Surname: *

First Name: *

Date of Birth: *

Please use this date format: DD/MM/YYYY

Address and Postcode: *

Email Address: *

Any responses we send will go to this email address.

Relationship to patient: *

Preferred Contact Number: *

Additional Number:

I wish to have online to view a medical record and understand and agree with each statement: *

I have responsibility for, and consent from the patient named above.

I have read and understood the Information Leaflet provided by the practice.

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

If I choose to share this information with anyone else, I understand the risks.

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

If I see information in the record that it not about the patient, or is inaccurate I will log out immediately and contact the practice as soon as possible.

*

I enclose a letter of authorisation from the patient.

*

I understand that access to the patients electronic record will be closed during the month of their 12th birthday.

Signature: *

Date:

To complete your registration, please upload proof of identity, this should include photographic ID and proof of address.

Maximum upload size: 67.11MB

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Register for online proxy access to medical record (children under 12 and carers)

Details of Patient

Details of Applicant