In accordance with the UK General Data Protection Regulation (UK GDPR)

Guidance notes – please read before completing this form:

Patients with online accounts, such as through the NHS App, should be able to read new entries in their health record and past record entries and data going back to 1st June 2024.

If a child aged 13 or over has ‘sufficient understanding and intelligence to enable him/her to understand fully what is proposed’ (known as Gillick Competence), then s/he will be competent to give consent for him/herself but may wish a parent to countersign as well. 

• Patients requiring access to their own record (Sections 1, 2 and 7)
• Proxy access to health records where patient has capacity (Sections 1, 3, 5, 6 and 7)
• Proxy access to health records where patient does not have capacity (Sections 1, 4, 5, 6 and 7)
• Parents requiring access to their child’s (age 13-17) record (Sections 1, 3, 5, 6 and 7)

I wish to access my medical record online and both understand and agree with each of the following statements (tick):

• 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 organisation

I/We wish to have proxy access to the health records on behalf of the above-named patient:

Proxy Applicant Details

I/We wish to have proxy access to the health records on behalf of the above-named patient

Proxy Applicant Details

I declare that the information given by me is correct to the best of my knowledge and that I am entitled to apply for access to the health records referred to above under the terms of the Data Protection Act 2018.  

You are advised that the making of false or misleading statements in order to obtain personal information to which you are not entitled is a criminal offence which could lead to prosecution

Under the Data Protection Act 2018, you do not have to give a reason for applying for access to your own health records. However, all applicants will be asked to provide two forms of identification, one of which must be photographic identification before access can be set up.

Please speak to reception if you are unable to provide this. 

Additional Notes

Before returning this form, please ensure that you have:

• Signed and dated the form
• Are able to provide proof of your identity or alternatively confirmed your identity by a countersignature
• Enclosed documentation to support your request (if applicable)