Records Access and Understanding Safety Checklist Questionnaire This form is used to sign people up for Full Records Access and Understanding How old is the patient 0 to 10 Years old 11 to 15 Years old 16+ Years old Child DetailsName First Last Telephone NumberDate of birth MM slash DD slash YYYY Address Street Address Address Line 2 City Postcode I wish to access the following below services on behalf of the above-named Child. I want the GP practice to let me manage the Child’s health online I know that I can change my mind or add/change the access arrangements for the Child at any time I understand the risks of allowing someone else to have access to the Child’s health records I want to book the Child’s appointments I want to order the Child’s medicines I want to be able to update the Child’s contact details I want secure online access to all of the Child’s electronic GP records Do you have parental responsibility for the child? I have parental responsibility for the Child Please tick one of the below: I am the birth mother I am the birth father and married to the mother at the time of child’s birth or subsequently I am the birth father and not married to the mother, but the child was born after 01/12/2003 and my name is on the birth certificate I am an adoptive parent I am the child’s legal guardian I have court-appointed parental responsibility Other PROXY DETAILS – enter your own details belowYour Name First Last Your date of birth MM slash DD slash YYYY Address Street Address Address Line 2 City Postcode Telephone NumberEmail Are you already registered at Silverdale Practice for GP online services? Yes No Please agree agree with each of the following statements. I will be responsible for the security of the information that I see or download If I choose to share information with anyone else, this is at my own risk I will contact the practice as soon as possible if I suspect that this account has been accessed by someone without my agreement If I see information in the record that is not about the Child or inaccurate, I will contact the practice as soon as possible Upload File Drop files here or Select files Max. file size: 1 GB, Max. files: 3. upload a picture of your official ID (driving license/passport etc)SignatureDate MM slash DD slash YYYY Patient DetailsName First Last Telephone number:Date of birth MM slash DD slash YYYY Address Street Address Address Line 2 City Postcode Fill in this section if you want access to your own online record (Your GP may want to discuss this form with you) I would like to have my own access Optional I know that I can change my mind about this at any time Optional I want to book my own appointments Optional I want to order my own medicines Optional I want to be able to update my own contact details Optional I want secure online access to all of my electronic GP records Optional Please agree agree with each of the following statements. I will be responsible for the security of the information that I see or download If I choose to share information with anyone else, this is at my own risk I will contact the practice as soon as possible if I suspect that this account has been accessed by someone without my agreement If I see information in the record that is not about the Child or inaccurate, I will contact the practice as soon as possible SignatureDate MM slash DD slash YYYY Fill in this section if you want to give someone else access (you can have your own access as well as other people) I want my GP practice to let other people help me manage my health Optional I know that I can change my mind about this at any time Optional I understand the risks of allowing someone else to have access to my health records Optional I want help to book my appointments Optional I want help to order my medicines Optional They can update my contact details for me Optional They can have secure online access to all of my electronic GP records Optional SignatureDate MM slash DD slash YYYY PROXY DETAILS NUMBER 1 – these are the people that you would like to help youName Full Name Telephone number:Date of birth MM slash DD slash YYYY Address Street Address Address Line 2 City Postcode Are you already registered at Silverdale Practice for GP online services? Yes No Email Relationship to patient:Please agree agree with each of the following statements. I will be responsible for the security of the information that I see or download If I choose to share information with anyone else, this is at my own risk I will contact the practice as soon as possible if I suspect that this account has been accessed by someone without my agreement If I see information in the record that is not about the Child or inaccurate, I will contact the practice as soon as possible SignatureDate MM slash DD slash YYYY PROXY DETAILS NUMBER 2 – these are the people that you would like to help youName Full Name Optional Telephone number:Date of birth MM slash DD slash YYYY Address Street Address Address Line 2 City Postcode Are you already registered at Silverdale Practice for GP online services? Yes No Email Relationship to patient:Please agree agree with each of the following statements. I will be responsible for the security of the information that I see or download If I choose to share information with anyone else, this is at my own risk I will contact the practice as soon as possible if I suspect that this account has been accessed by someone without my agreement If I see information in the record that is not about the Child or inaccurate, I will contact the practice as soon as possible SignatureDate MM slash DD slash YYYY Upload File Drop files here or Select files Max. file size: 1 GB, Max. files: 4. upload a picture of each persons official ID (driving license/passport etc)