Online Report Access Application Form

Title: *

Mr

Mrs

Miss

Ms

Surname: *

First Names: *

Date of Birth *

Please use format DD/MM/YYYY

Email Address: *

All responses will go to this email.

Postcode: *

Current Address: *

Home Telephone:

Mobile Telephone:

General Questionnaire

Please answer the following questions when considering if you would like online access to your medical records

I am doing this questionnaire for myself *

Yes

No

What is your relationship to the patient? *

Can you read and understand English? *

Yes

No

Have you registered for ordering repeat prescriptions and booking appointments online? *

Yes

No

Are you happy to use passwords to access your record? *

Yes

No

Would you like to feedback what you think of the records access system? *

Yes

No

There may be an instance when accessing your medical records online, you may read some information that could be shocking or upsetting. What do you do if this happens and you cannot speak to your doctor/nurse immediately?

Wait until you see the doctor/nurse for them to explain further

Panic and get worked up

Look at reputable websites like NHS choices

Wait and contact the practice the next working day

Contact NHS Direct (111) to get further information

Contact GoToDoc, the out of hours service

Go to A&E for further help

Would it upset yo if you read something somebody else has said about you with regards to your health?

No

Yes - I don't want this information kept in my records

Yes - You should not believe what others say

Yes - This could destroy our relationship

Don't Know

Do you feel you understand what Online Records Access means? *

Yes

No

Online Access

I wish to have access to the following online services (please tick all that apply)

Requesting repeat prescriptions

Booking and cancelling appointments

Accessing my medical records summary

Accessing my detailed coded medical records

I wish to access the information I have specified above online and understand and agree with each statement below (tick) *

I have read and understood the information leaflets provided by the practice

I have not been coerced or pressured into requesting access to my medical records

I will be responsible for the security of the information that I see or download

If I choose to share my information with anyone else, that is at my own risk

I will contact the practice as soon as possible if I suspect that my account has been accessed by someone without my agreement

If I see information in my record that is not about me or is inaccurate, I will contact the practice as soon as possible

I agree to use the system responsibly and I am aware that access will be removed as a result of abuse of the system

Please note if you do not agree to all the above points your application will be declined.

Signature of the patient: *

Date:

Online Report Access Application Form

General Questionnaire

Online Access

For office use only

Hay Fever

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Online Report Access Application Form

General Questionnaire

Online Access

For office use only

Hay Fever