Name *

First Name

Last Name

Date of birth *

MM

DD

YYYY

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

I give permission to Cricket Green Medical Practice to give my representative proxy access to the online services as indicated below: *

Booking appointments

Requesting repeat prescriptions

Access to parts of my medical record as currently available

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 *

Date

MM

DD

YYYY

Name *

First Name

Last Name

Date of birth *

MM

DD

YYYY

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

I wish to have online access to the services ticked in the box above in patient's section. I understand my responsibility for safeguarding sensitive medical information *

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 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 *

Date *

MM

DD

YYYY