Online Access Proxy & Historical Medical Record

Full Patient Access Registration Form

Make appointments, repeat request prescriptions & view your medical record online.

All patients registering at the Chislehurst Medical Practice will have full record view automatically enabled dating from the date of registration.

Once you are registered for the Patient Access System you are able to; – make appointments, request prescriptions and view your GP medical record online.

If you would like to have secure online access to your historical records, we need to make sure that you understand what this involves and that you are happy for us to use the information provided below to set up and operate the service. You will need to provide one form of photographic ID; e.g. Passport or driving licence.

The following form will take you through the things you need to think about. The practice makes every effort to record information as accurately as possible, however there may be information that you do not feel is correct.

By submitting this form you accept the declarations listed below and will be giving us your permission to go ahead with setting up the service for you (subject to your specific access requests). If you decide not to join, or wish to withdraw, it will not affect your treatment in any way.

Conditions of Use

1. I have read and understood this information leaflet about this service and access to GP medical records.

2. I agree to use the system in a responsible manner in accordance with all instructions given to me by the practice. If not, access may be withdrawn.

3. If I see information which does not relate to me, I will immediately log out and report the matter to the practice as soon as possible.

4. I agree that it is my responsibility to keep my username and passwords secure. If I think these have been shared inappropriately I will reset them using the instructions supplied. I am also responsible for keeping safe any information I may print from the record.

5. I agree that my details below may be used to contact me about how useful I find the service and whether it could be improved.

6. If I notice any inaccuracies with my record, I will inform the Practice Manager as soon as possible of any errors or omissions.

I understand that I may see information on my record that I was unaware of / have forgotten about that could cause distress.

Applicants requiring online access to full medical record

Sight of ID required

Who is requesting access?

Requesting for myself

Requesting on behalf of a child under 13 or for a patient for whom you have legal responsibility

Patient Details

Full Name

First Last

Patient's Date of birth

Address

Street Address Address Line 2 City Postcode

Mobile Number Optional

Enter Email Optional Confirm Email Optional

If you are requesting on behalf of a child under 13 or for a patient for whom you have legal responsibility, please give your details below.

Parents / Guardians & Carers Full Name

First Last

Parents / Guardians & Carers Date of birth

Parents / Guardians & Carers Address

Street Address Address Line 2 City Postcode

Parents / Guardians & Carers Email

Enter Email Confirm Email

Relationship to patient

Please tick one one option.

I am the patient detailed above

I am the legal parent/guardian of the child named above and the child is under 13

I have legal responsibility and consent to access the record of patient named above

Please tick as applicable.

I have not yet registered and wish to request access to view my medical record

I have read and accept the conditions of use

Name Optional

This field is for validation purposes and should be left unchanged.