Proxy Access

Please select the practice location most relevant to this Online Form submission:

Proxy Access

Patient First Name/s

Patient Surname

Patient Date of Birth

Patient Email Address

Patient Phone Number

Patient information

Proxy is the person having access to a patients medical records on their behalf. This can be a parent/guardian or carer of the patient. You will be required to provide photo ID and be present when returning the forms to reception. Please see below fo

Children under the age of 14;

Proxy to provide photo ID

Children over the age of 14;

Child to provide photo ID or birth certificate, Proxy to provide photo ID, Child to be present when form is returned to reception

Guardian

To provide documentation that states legal guardianship of patient, To follow guidance as above for children

Carer

Proxy to provide Photo ID, Patient to provide Photo ID, Patient does not need to be present when form is returned if housebound.

Consent to proxy access to GP online services

Full access to the medical records

I/we will be responsible for the security of the information

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

Proxy Access For GP Online Services

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

First name

Surname

Date of birth

Address

Mobile

Proxy Access For GP Online Services.

I the patient, give permission to my GP practice to give the following as listed above proxy access to the online services as indicated below

Yes

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

**This service is intended for electronic communication between you and your Practice. The information may be read by any member of the Practice team and responded to by the most appropriate member of the team. Your Practice will endeavour to respond within the timeframe set for this form but will not be able to respond to urgent requests through this service.**

Confirm

Please check this box to confirm you have read and understood this statement

Privacy Protection

Information submitted through secure forms is used only for the purposes of processing your request. We may be in touch with you in relation to the information submitted.

All Information submitted through secure forms is secured with a private key and is accessed over a secure connection by nominated staff. We have a strict confidentiality policy.

This information is not shared with any third party organisations.

This information is retained for up to 28 days.

I consent to my information being used for the purposes described above and wish to submit this online form to Gallions Reach Health Centre • Bentham Road, London, SE28 8BE.

Learn more about our Privacy Policy and Terms of Use. Should you have any concerns about sending your personal details using the web, please use one of the alternative methods offered by our organisation.