Under 12 Proxy Access Child Application for Online Access to Medical Records (Under 12 proxy access) Details of childSurname Last Date of Birth Day Month Year First Name(s) First Address Street Address Address Line 2 City / Town County Post Code Email PhoneDetails of Parent/ Guardian requesting accessBefore the Practice provides parental proxy access to a child’s medical records the following checks must be made: The identity of the individual(s) requesting access via the proxy request form That the identified person is named on the birth certificate of the child or adoption certificate In the case of a child judged to have capacity to consent, there must be the explicit informed consent of the child.Surname 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 PhoneAccess & AgreementI wish to have access to the following online services (please tick all that apply): Booking appointments Requesting repeat prescriptions Access to tests results Accessing my prospective full medical record Select AllI wish to access my medical record online and understand and agree with each statement I have read and understood the “Accessing your GP-held records via the NHS app or NHS website information” on the Acorn Surgery website and understand the risks involved. I understand that I am responsible for the security of any information that is seen, downloaded or printed. If I choose to share my child’s 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 my child’s 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 If not access may be withdrawn.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 my child’s 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
