YORKSHIRE STREET SURGERY			
188-190 Yorkshire Street
Rochdale	
OL16 2DN						
Telephone 01706 390243
Email hmrccg.yorkshirestreetsurgery@nhs.net

CONSENT TO PROXY ACCESS TO GP ONLINE SERVICES

Name:	Email:	DOB:	
Section 1:  Children under 11 – Representative to complete 
I, ………………………………………………………… (name of patient), give permission to Yorkshire Street Surgery to give the following people proxy access to online services as indicated below in section 2: ……………………………………………………………………………………………………………………
Section 2: 

1.	Booking Appointments		
2.	Requesting repeat prescriptions		
3.	Accessing my coded medical records, including immunisations, medications and consultations.		

 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 provided by the practice.

Signature of Patient *: …………………………………………………Date: ………………………
(Children aged under 11 – not required to sign) 

The Patient (the person whose online records are to be accessed)

Surname: 							Date of birth:
First name:
Address:
Postcode:
Email address:

Telephone number: 					Mobile number:

The Representative (the person seeking proxy access to the patient’s online services)

Surname: 							Date of birth:
First name:
Address:
Postcode:
Email address:
Telephone number: Mobile number:

I, ………………………………………………………… (name of representative) wish to have online access to the services ticked in the box above in section 2 for:
…………………………………………………………… (name of patient).

PLEASE COMPLETE THE THIS SECTION AND RETURN TO RECEPTION

1.	I have read and understood the information provided by the practice and agree that I will treat the patient information as confidential.		
2.	I will be responsible for the security of the information that I see or download.		
3.	If I choose to share my information with anyone else, this is at my own risk.		
4.	I will contact the practice as soon as possible if I suspect that the account has been accessed by someone without the agreement of the patient.		
5.	If I see information in my record that is not about me or is inaccurate, I will contact the practice as soon as possible.		
6.	If I think that I may come under pressure to give access to someone else unwillingly I will contact the practice as soon as possible.		
7.	I understand my responsibility for safeguarding sensitive medical information.		
8.	If I see information in the record that is not about the patient, or is inaccurate, I will contact the practice as soon as possible. I will treat any information which is not about the patient as being strictly confidential.		

Signature of Representative	Date:	

Present this completed form in person to one of our receptionists who will verify 
your ID and print off your username/s and password/s.   

For practice use only

Patient NHS Number 	Practice computer ID number 	
Identity verified by (initials)	Date	Method
Vouching with information in record o
Photo ID and proof of residence o	
Authorised by	Date	
Date account created	
Date passphrase sent	
Level of record access enabled
All o 
Prospective o Retrospective o
Detailed coded record o 
Limited parts o 	Notes / explanation