Child Proxy Online Access to Medical Records

If you would like to request proxy online access to a child’s medical records, please use this form.

If you are human, leave this field blank.

Patient Information

Patient Full Name: *

Date of Birth: *

Please use format: DD/MM/YYYY

Contact Email Address: *

Any responses we send will go to this email address.

Patients Age:

Preferred Telephone Number: *

Additional Telephone Number:

Proxy Information

Full Name of Proxy: *

Relationship to Patient: *

Terms and Conditions

I would like to acces to be able to view my child's GP medical record online.
To obtain proxy access, the parent must be registered for online access at our practice.
One parent, with parental rights, may request proxy access for their child under the age of 11.
Parent with proxy access will be able to book appointments and order repeat prescriptions for the child and will also have access to the elements of the child's patient record that have been release for online access.
The parent must show proof of ID and proof of parental right e.g. birth certifiicate, at the time of requesting proxy access for their child. If there are any limimtations on access to child or their information imposed by Court or Social Services, it must be declared.

I have read and understood the above, I have read and understood the Patient Information Leaflet for online access and adhere to use the system in a responsible manner in accordance with all instructions given to me by my GP practice. I agree to inform the practice as soon as possible of any problems/errors I see whilst using the system.

Confidentiality and Young People

Please note that access granted to a parent/guardian will end once the child reaches 11 years.
The young person shouled complete and sign a new consent form if they wish to continue with online access to their medical records.
Anyone over 16 is presumed to have consent to access online medical records.
Young people under 16 years are sometimes competent to make important decisions themselves. The Practice will take this into account if they do not wish to grant access to their medical records to a parent.

Patient Signature: *

Date:

Mersham Medical Centre

Child Proxy Online Access to Medical Records