12 and Over Parent Proxy Child Application for Online Access to Medical Records (12 and Over Parent Proxy) Patient To CompleteSurname Last Date of Birth Day Month Year First Name(s) First Address Street Address Address Line 2 City / Town County Post Code Email PhoneI wish to give Proxy Access to the following personSurname Last Date of Birth Day Month Year First Name(s) First Relationship to patient Are you registered at our organization? Yes No Address Street Address Address Line 2 City / Town County Post Code Email PhoneI wish the above person to have access to Booking appointments Requesting repeat prescriptions Access to test results Accessing my prospective full medical record Select AllCoercion“Coercion” is when somebody forces an individual to act against their will. This can be through threatening them, overwhelming them, or hurting them. Coercion might result in patients being forced into sharing information from their record, including login details, medical history, repeat prescription orders, GP appointment booking details and other private, personal information. Coercion Consent I agree with the following statements• I confirm that I have not been coerced in any way • I have read and understood the information provided in the ‘Proxy Access to GP Online Services – Information Leaflet for Children’ and the risks that may be associated. • I understand that the following access will be revoked when I reach the age of 16 and 18. I will have to resubmit this a new request should I wish for access to be reinstated Signature of PatientParent / Guardian To CompleteI understand and agree with each statement I understand that I am responsible for the security of any information that is seen, downloaded or printed. If I choose to share information with anyone else, this is at my own risk. I will contact the practice as soon as possible if I suspect my account has been accessed by someone without my agreement. If I see information in the record that is not about them or is inaccurate, I will contact the practice as soon as possible. I agree to use the system in a responsible manner. If not access may be withdrawn. I agree that it is my responsibility to keep my username and password secure. If I think these have been shared inappropriately, I will take the appropriate action, reset the password and inform the Practice. I understand that I may see information on the record record that I was unaware of or have forgotten about that could cause me distress. I understand that I will be informed by the Practice of any test results that require action. However, I understand I may see these results online before the Practice has been able to contact me. This could be while the Surgery is closed and there is no one available to discuss with me. I understand that I may see information that relates to significant diagnosis before the GP or hospital specialist has had the opportunity to discuss with me This may relate to diagnosis, prognosis and treatment options and that this may cause me distress. I understand that there may be medical terminology used within my child’s records that I do not understand and that it will take time to arrange for a member of the team to be able to explain the relevant terminology with me and that this could cause me distress. SignatureI understand that the following access will be revoked when the child reaches the age of 12, at which point a new request will need to be submitted by them should they wish for my proxy access to be reinstated.Parent/Guardian Name First Last
