Rye Medical Centre

Online Access Application c1.001

"*" indicates required fields

First name*

Surname*

Date of birth*

Day

Month

Year

Address*

Postcode*

Email address*

Telephone number*

Mobile number

I wish to have access to the following online services (please tick all that apply):*

Booking appointments

Requesting repeat prescriptions

View Summary Information ( Medications, Allergies, Vaccinations)

View detailed information

Confirmation*

I have read and understood the information leaflet provided by the practice. I will be responsible for the security of the information that I see or download. I understand I may read some information that could be unexpected or upsetting. If I choose to share my information with anyone else, this is at my own risk. I will contact the practice as soon as possible if I suspect that my account has been accessed by someone without my agreement. If I see information in my record that is not about me or is inaccurate, I will contact the practice as soon as possible.

I wish to access my medical record online and understand and agree with the following statements

Not for urgent medical help*

Yes, I understand this form is NOT for urgent medical help

Consent*

By submitting your details you are consenting to providing this information for improving our services to you. The data you supply on this form will be securely stored on our website, which is hosted by a third party. We will retain this information on the website for no longer than 7 calendar days. your contact details will not be sold or shared with a third party. I understand I can revoke this consent at anytime by contacting the practice. Our privacy policy can be viewed on this website.

I agree to the privacy policy.

Signature*

Type your name to sign the form. The practice may still need you to sign in person before they can provide you with login details.

Date*

Day

Month

Year

Online Access Proxy Request c1.001

"*" indicates required fields

Section 1

Patient first name*

Patient surname*

Proxy access consent*

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 agree to the proxy access consent above.

Section 2

I (the patient) consent to give proxy access to the following online services (please tick all that apply):*

Online appointments booking

Online prescription management

Limited access to parts of the medical record for (name of patient) (Medication, Allergies, vaccinations))

Section 3

Representative first name*

Representative surname*

Proxy access agreement*

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

Safeguarding agreement*

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.

I understand my responsibility for safeguarding sensitive medical information and I understand and agree with each of the above statements.

Patient details

(This is the person whose records are being accessed)

First name*

Surname*

Date of birth*

Day

Month

Year

Address*

Postcode*

Telephone number*

Mobile number

Representative details

(The person seeking proxy access to the patient’s online records, appointments or repeat prescription.)

First name*

Surname*

Date of birth*

Day

Month

Year

Address*

Postcode*

Email address*

Telephone number*

Mobile number

Relationship to patient*

Legal basis reason for proxy access*

Parental responsibility

Power of Attorney

Guardian/Carer

Consent

Consent*

I agree to the privacy policy.

Not for urgent medical help*

Yes, I understand this form is NOT for urgent medical help

Online Access Application c1.001

Online Access Proxy Request c1.001

Section 1

Section 2

Section 3

Patient details

Representative details

Consent

Helpful links

Further Info