Consent to proxy access to GP Online Services

 
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Note: If the patient does not have capacity to consent to grant proxy access and proxy access is considered by the practice to be in the patient’s best interest section 1 of this form may be omitted.

Section 1

proxy access to the online services as indicated below in section 2.

  • I reserve the right to reverse any decision I make in granting proxy access at any time.
  • I understand the risks of allowing someone else to have access to my health records.
  • I have read and understand the information leaflet provided by the practice
Section 2
Section 3

I/we understand my/our responsibility for safeguarding sensitive medical information and I/we understand and agree with each of the following statements:

Section 4

The patient 
(This is the person whose records are being accessed)

The representatives 
(These are the people seeking proxy access to the patient’s online records, appointments or repeat prescription.) 

 

Privacy Consent

This form collects personal and medical information about you. We use this information to allow the practice team to contact you. Please read our Privacy Policy to discover how we protect and manage your submitted data.

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Providing NHS Services

Hetherington Group Practice
18 Hetherington Road
London
SW4 7NU

Telephone: 020 7274 4220

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