Alert – Norovirus (Vomiting bug)

The Norovirus, also known as the vomiting bug, is currently spreading more than usual in the community. There are two types of the virus, so it’s possible to get sick from it more than once. Most people feel better after about 3 days (72 hours). How to Care for Yourself: If you’re worried about babies,

Contact us online. Get help from your GP with our online consultation service.

Parental Proxy Access Form

Parental Proxy Access Request

Adult Requestor

First Name *

Last Name *

Date of birth *

Please use format day/month/year e.g. 12/05/1979

Address

Please include postcode

Email *

I confirm I am a patient of The Adam Practice

The Practice can only link accounts where both parties are registered patients.

Child Details

First Name *

Last Name *

Date of birth *

Please use format day/month/year e.g. 12/05/1979

Age *

Address

Please include postcode

I confirm the named child is a patient of the practice.

The Practice can only link accounts where both parties are registered patients.

I confirm that there are no reasons, including existing court orders, preventing me from having access to the named child’s medical record.

I confirm I have parental responsibility for the above named child.

Please upload:

a copy of 2 forms of ID, this should be passport or photo driving licence, and a bank statement.
the child’s birth certificate, showing proof of parental responsibility.

If you do not confirm parental responsibility your request will automatically denied.

File Upload

Maximum file size: 10MB

Proxy Access

I would like to request access to the following:

Requesting prescriptions

Questionnaires

Please tick all that apply.

As a practice full record access is only given where there is a significant medical need for the parent to view the child’s full medical notes.

I would like to request full record access.

Please give the reason(s) why you require full record access

Signature

Clear

Privacy Policy

This form collects your name, date of birth, email, other personal information and medical details. This is to confirm you are registered with the practice, to allow the practice team to contact you and also to update your medical records held by the practice and our partners in the NHS. Please read our Privacy Policy to discover how we protect and manage your submitted data.

I consent to the practice collecting and storing my data from this form.

If you are human, leave this field blank.

Alert – Norovirus (Vomiting bug)

Parental Proxy Access Form

Adult Requestor

Child Details

Proxy Access

Privacy Policy

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