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
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
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.
Should you have any concerns about sending your personal details using the web,
please use one of the alternative methods offered by our organisation.