Patient (the person whose records are being accessed)

First name
Last name

Email
Address (including postcode)

Section 2 — Services requested

Online appointments bookingOnline prescription managementAccessing the medical record for the patient

Section 1 — Patient consent

I, the patient named above, give permission for the representative(s) below to have proxy access to the services selected.

Patient signature (type full name)
Date

Section 3 — Representative(s)

(Duplicate the above block for additional representatives if needed.)

Representative responsibilities

I/We have read and understood the information provided by the practice.

Your details

First name
Last name

Email
Named GP (if known)

Medical report type

HGV/PSV MedicalsTaxi MedicalsOccupational Health AdviceOther
If Other, please specify
Why do you need this report?

I confirm the information provided is correct.

Your details

First name
Last name

Email

About you

Are youMaleFemaleOther
How often do you come to the practice? [radio* attendance use_label_element "Regularly" "Occasionally" "Very rarely"]
Ethnic background—Please choose an option—White BritishWhite IrishWhite and Black CaribbeanWhite and Black AfricanWhite and AsianIndianPakistaniBangladeshiCaribbeanAfricanChineseOther
Age group—Please choose an option—Under 1617 – 2425 – 3435 – 4445 – 5455 – 6465 – 7475 – 84Over 84

I consent to the practice contacting me about Patient Participation Group matters.

Your details (carer)

First name
Last name

Email
Address including postcode
Is the person you care for a patient at this surgery? [radio* caredfor-registered use_label_element "Yes" "No"]

Person being cared for

Full name
Date of birth (DD/MM/YYYY)
Address including postcode
Relationship to you

I confirm the information provided is correct.

Your details

First name
Last name

Email
Address, including postcode

Online services requested

Booking AppointmentsRequesting Repeat MedicationsAccessing My Medical Record

Declarations

I have read and understood the NHS approved information leaflet provided by the practice.

I will be responsible for the security of the information that I see or download.

If I choose to share my information with anyone else, this is at my own risk.

If I suspect unauthorised access, I will contact the practice as soon as possible.

If I see information that is not about me or is inaccurate/upsetting, I will contact the practice as soon as possible.

If I think I may come under pressure to give access to someone else unwillingly, I will contact the practice as soon as possible.

I accept the terms and conditions stated above.

Signature (type full name)
Date

Who are you completing this form for? [radio* who-for use_label_element "Yourself" "Someone else"]

Your details (or dependent’s details)

First name
Last name

Email

Your decision

Opt Out (do not allow identifiable data to be shared beyond direct care)Withdraw Opt-Out (allow identifiable data to be shared beyond direct care)

Your declaration

I confirm the information I have given is correct. If acting for someone else, I confirm I am the parent or legal guardian.

Signature (type full name)

Section A — Patient details

First name
Last name

Address (including postcode)
NHS number (if known)
Phone
Email

Section B — If you are completing on behalf of the patient

Your name
Electronic signature (type full name)
Relationship to patient

I request to opt out of having a Summary Care Record created for me/the patient named above.

Your details

First name
Last name

Email
Who were you waiting to be referred to?
Any further details