Proxy Access Patient Consent Form 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 NumberPatient 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. 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 Please enter your full name as registered in the practiceDate 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 Relationship to Patient Proxy User Signature Please enter your full nameDate Day Month Year Proof of ID and Address of yourself (patient) and proxy user Drop files here or Select files Max. file size: 50 MB. Please upload proof of your ID and recent proof of addressPlease upload a picture of yourself (patient) with poster or paper showing today's dateMax. file size: 50 MB.This will help us to verify consent more quicklyConsent 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 Phone OptionalThis field is for validation purposes and should be left unchanged.
