Application for Online or Proxy Access

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Application for Online Access

Please complete this form to request online access, including proxy access, to  your medical records

Online access allows you to order repeat prescriptions and see information in your medical record, including medications and allergies.

  • We have a responsibility to look after your GP records.
  • You must also take care online and make sure your personal information is not seen by anyone who should not see it.
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All questions marked with a * are mandatory

Keeping your password safe

Keeping your username and password safe

When you register to use Online Services, you will create your own username and password, which you will use to log in. You should not share your log in details with others.

To protect your information from other people:

  • You should keep your password secret and it is best not to write it down. If you must write it down, keep a reminder of the password, not the password itself. This should be kept in a secure place.
  • If you think someone has seen your password, you should change it as soon as possible. You may want to call the surgery if you are not able to change it right away, for example, when you do not have access to the internet.
  • You should not share your user name or password. No one should force you to show them your log in details, you have the right to say no. If someone forces you, tell the surgery as soon as possible.
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Using a shared computer

In order to protect your personal information, you need to take extra care when using a shared computer to look at your medical record online. This could be at the library, at work, at university or at home. 

You should:

  • Look around to see if other people can see what is on the computer screen. Remember, your records contain your personal information. 
  • Keep your username and password secret. Just like your bank account PIN you would not want others to know how to get into your medical record.
  • Make sure you log out when you finish looking at your record so that no one else can see your personal information or change your password without your knowledge.
Shared computer
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Incorrect information in your records

Incorrect information in your record

On rare occasions information in your records might be incorrect.

  • If you find any incorrect information you should let us know as soon as possible.
  • If you see information about anyone else in your records, log out immediately and let us know as soon as possible.
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  • Patients under the age of 16 cannot have their own online account
  • Patients over the age of 16 must have their own personal email account which cannot be shared
I am: *
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Details of the Patient
Please double check you've entered the correct email address
I wish to have access to the following online services: *
Details of the applicant(s)
 
Do you need to add a second applicant?: *
 

Should you need additional applicants, please submit another form once completing this one

Access to the the following is required on behalf of

Booking Appointments: *
Requesting Repeat Prescriptions: *
Access to Medical Records: *
Access to Test Results: *
Reason for access: *
Reason for access: *

If you are making an application on the behalf of somebody else we require evidence of your Authority

Please upload a copy your supporting documents

  • You can upload a document, photo or scan

We require evidence of your Authority or Birth Certificate

Please upload a copy your supporting documents

  • You can upload a document, photo or scan
Only following file extensions are allowed: jpg, jpeg, png, webp, pdf, doc, docx, pptx
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Proof of Identity
NHS Logo

Identification

We are required to check your identity before granting access to your medical record

Acceptable forms of Photo ID

  • Photo Driving License
  • Passport

ID documents are not stored and will be securely destroyed in line with our data retention schedule.

Acceptable forms of Proof of Residence

  • Tenancy agreement
  • Mortgage statement
  • Bank statement
  • Utility bill (dated within the past 3 months) 

Please upload a copy of 's ID and Proof of Address

  • You can upload a document, photo or scan
Please upload a copy of your Photo ID and Proof of Residence
  • You can upload a document, photo or scan
Only following file extensions are allowed: jpg, jpeg, png, webp, pdf, doc, docx, pptx
Only following file extensions are allowed: jpg, jpeg, png, webp, pdf, doc, docx, pptx
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To be completed by the Patient

I, , give permission to my GP practice to give the following people proxy access

    

Proxy access will be given to the following online services

  • Booking appointments: 
  • Requesting repeat prescriptions: 
  • Access to my medical records: 
  • Access to test results: 
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: *
Patients requiring access to their own record
I have read and understood the information provided by the practice on the previous pages: *
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, this 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.: *
Proxy declaration

 , as the lead applicant agree the following and sign.

I have read and understood the information provided by the Practice and agree that I/we will treat the patient information as confidential: *
I will be responsible for the security of the information that I/we see or download: *
I will contact the practice as soon as possible if I/we suspect that the account has been accessed by someone without my/our agreement: *
If I see information in the record that is not about the patient or is inaccurate, I/we will contact the Practice as soon as possible. I/we will treat any information which is not about the patient as being strictly confidential: *
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 record referred to under the terms of the Data Protection Act 2018.: *
I understand that the making of false or misleading statements in order to obtain personal information to which I am not entitled is a criminal offence which could lead to prosecution.: *
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Providing NHS Services

Contact

Montgomery-House Surgery
Piggy Lane
Bicester
OX26 6HT

Telephone: 01869 249222

The Practice

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