Application for Online Access to Medical Records (11 years or younger)

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Application for Online Access

Online access to medical records (11 years or younger)

In line with our Online Patient Access policy, it is the Usual GP's decision if access is granted to the parent/ guardian of the patient (as a proxy).

  • Please complete this form and you will be contacted by a member of the practice once the application has been considered
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All questions marked with a * are mandatory

Keeping your password safe

Keeping your username and password safe

When you register to use Online Services, you will create your own username and password, which you will use to log in. You should not share your log in details with others.

To protect your information from other people:

  • You should keep your password secret and it is best not to write it down. If you must write it down, keep a reminder of the password, not the password itself. This should be kept in a secure place.
  • If you think someone has seen your password, you should change it as soon as possible. You may want to call the surgery if you are not able to change it right away, for example, when you do not have access to the internet.
  • You should not share your user name or password. No one should force you to show them your log in details, you have the right to say no. If someone forces you, tell the surgery as soon as possible.
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Using a shared computer

You need to take extra care when using a shared computer to look at your records online. This could be at the library, at work, at university or at home. To protect your personal information from others when using a shared computer. 

You should:

  • Look around to see if other people can see what is on the computer screen. Remember, your records contain your personal information. Look around
  • Keep your username and password secret. Just like your bank account PIN you would not want others to know how to get into your records.
  • Make sure you log out when you finish looking at your records so that no one else can see your personal information or change your password without your knowledge.
family-using-laptop
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Incorrect information in your records

Incorrect information in your records

On rare occasions information in your records might be incorrect.

  • If you find any incorrect information you should let the surgery know as soon as possible.
  • If you see information about anyone else in your records, log out immediately and let the surgery know as soon as possible.
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Details of the Patient (Child's details)
Please double check you've entered the correct email address
I wish to have access to the following online services: *
Details of parent/ guardian applying for online access on behalf of above named patient
Are you registered as a patient at this Practice?: *
Do you need to add a second applicant?: *
Is your address the same as the child?:
Reason for access: *
Reason for access: *

If you are making an application on the behalf of somebody else we require evidence of your Authority

Please upload a copy your supporting documents

  • You can upload a document, photo or scan

We require evidence of your Authority or Birth Certificate

Please upload a copy your supporting documents

  • You can upload a document, photo or scan
Only following file extensions are allowed: jpg, jpeg, png, webp, pdf, doc, docx, pptx
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Proof of Identity
NHS Logo

Identification

We are required to check the identity of all applicants

Acceptable forms of Photo ID

  • Photo Driving License
  • Passport

ID documents are not stored and will be securely destroyed in line with our data retention schedule.

Acceptable forms of Proof of Residence

  • Tenancy agreement
  • Mortgage statement
  • Bank statement
  • Utility bill (date within the past 3 months) 

Please upload a copy of 's ID and Proof of Address

  • You can upload a document, photo or scan
Please upload a copy of your ID and Proof of Address
  • You can upload a document, photo or scan
Only following file extensions are allowed: jpg, jpeg, png, webp, pdf, doc, docx, pptx
Only following file extensions are allowed: jpg, jpeg, png, webp, pdf, doc, docx, pptx

Please upload a copy of %%form-element-4846%%'s ID and Proof of Address

  • You can upload a document, photo or scan
Only following file extensions are allowed: jpg, jpeg, png, webp, pdf, doc, docx, pptx
Only following file extensions are allowed: jpg, jpeg, png, webp, pdf, doc, docx, pptx

Please upload a copy of  's ID and Proof of Address

  • You can upload a document, photo or scan
Only following file extensions are allowed: jpg, jpeg, png, webp, pdf, doc, docx, pptx
Only following file extensions are allowed: jpg, jpeg, png, webp, pdf, doc, docx, pptx
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I wish to access my medical record online and understand and agree with each statement

I/We agree to the following:

Privacy Consent

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