Patient Access Consent Form

Please note when completing the form

Children under the age of 12 – Parents can automatically consent to access

Children over 12 but under 16 – Children are entitled to confirm consent to parents to have access

Carers – named person is entitled to confirm consent to carer to have access unless patient lacks mental capacity

Agreement to Practice Guideline for the use of Patient Access

I have understood and will adhere to the practice guidance for the use of Patient Access

I understand that failure on my part to adhere to the guidance may result in my Patient Access registration being terminated.

I understand that this will in no way affect my registration with the practice

If you are applying for yourself only you only need to complete section 1.

If you are requesting Proxy Access for another person please complete sections 1 and 2. If the person you are requesting Proxy Access for is aged 12 or over please ask them to complete section 3.

Section 1: Patient’s Details (The person whose record is to be accessed on line via Patient Access)

Surname

First Names

Date of Birth

Section 2: Details of person to be given access to this patient’s online information

Full Name

Address

Section 3: Consent

I consent for the above named person to be able to access my online medical record

Name of the person providing consent

Date

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 Bilston Family Practice • Bilston Health Centre, Prouds Lane, Bilston, WV14 6PW.

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.

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