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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

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)
Section 2: Details of person to be given access to this patient’s online information
Section 3: Consent

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.

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.


Your Neighbourhood Professionals. Just a Click Away! Church Street Dental Practice, Bilston
Your Neighbourhood Professionals. Just a Click Away! Church Street Dental Practice, Bilston