Viewing your electronic health records online Name First Last Date of Birth Day Month Year Address Postcode Contact NumberEmail Enter Email Confirm Email Date of completion:I am over the age of 16? Yes No You do not meet the age criteria.Please upload your ID and proof of address Drop files here or Select files Max. file size: 50 MB. I am doing this questionnaire for myself. Yes No Please state your relationship. Can you read and understand English? Yes No Have you registered for ordering repeat prescriptions and booking appointments on-line? Yes No Are you happy to use passwords to access your record? Yes No After you have been to the doctor or to the hospital, you can check if the encounter has been recorded and what was discussed. Do you agree this is a good reason to have access to your records? Yes No Would you like to feedback what you think of the Records Access system? Yes No There may be an instance when accessing your medical records online, you may read some information that could be shocking or upsetting. What do you do if this happens and you cannot speak to your doctor/nurse immediately? (Please tick all that apply) Not view the test results but wait until you see a Clinician Panic and get worked up Look at reputable websites like NHS Choices or check the Health A-Z section Wait and contact the practice the next working day Contact 111 to get further information Go to A&E for further help You see a new letter has arrived in your electronic health record. You open up the letter to find it is about another patient in the practice. What do you do? Read it and tell that person what you have read Inform the practice Don’t tell anybody about it Would it upset you if you read something somebody else has said about you with regards to your health? No Yes – I don’t want this information kept in my record Yes – You should not believe what others say Yes – this could destroy our relationship Don’t know Do you feel you understand what Records Access means? Yes No SignaturesName of patient you are completing this form on behalf of First Last Name First Last Your Name First Last Your Signature Signature I confirm that the information I have provided is true to the best of my knowledge