SystmOne Online – Patient application form

(for parents/guardians applying for proxy access for under 11’s)

The Hadleigh Practice will allow parents or guardians proxy access to SystmOne Online for their child under the age of 11 to be able to book appointments and order medication. Please note that due to complex confidentiality laws and online access guidance The Hadleigh Practice does not allow access for children aged 11- 16 years old. At 16 the child can register themselves for online access.

To apply for proxy online access for your child you will need to already be registered for SystmOne online yourself. You will then need to bring along this form, together with photographic ID for yourself, proof of relationship to the child (eg birth certificate or proof of guardianship) and if possible, ID for your child. To ensure confidentiality we are only able to accept proxy access registrations in person – i.e. you cannot give your details to anyone else to register for you.

Details of Child you are applying access for :

NAME:
Date of birth: Age:

Your details:

NAME:
Relationship to child:
Email Address:

Patient Disclaimer

I ……………………………..……………………………………am the parent / guardian of ……………………………………….. and I am applying for online access for the child. I will adhere to the Hadleigh Practice’s Guidance notes which I have been given for the use of SystmOne Online. I understand that it is my responsibility to keep the account secure by keeping the log in details confidential. I understand that I can terminate the account at any time by contacting the surgery, or change the log in details by re-registering, and that this form will be kept on the child’s electronic records. I understand that at age 11 the online access will automatically expire as no access is given for children aged 11-16 years old. At 16 years old the child will need to request to register themselves in person.

Signed: ………………………………………………. Date:……………….

------Surgery staff to complete:

ID for parent seen £ type of id ……………….…………………. / Staff Name ………………..… Date: ………………
Proof of relationship (birth cert/proof of guardianship) £ / Staff name ……………………Date: ………………