Online access proxy request

I, the patient, give permission to my GP practice to give the following person 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.

I have read and understood the information leaflet provided by the practice and agree that I will treat the patient information as confidential. I will be responsible for the security of the information that I see or download. I understand we may read some information that could be unexpected or upsetting. I will contact the practice as soon as possible if I suspect that the account has been accessed by someone without my agreement. 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.