Important - Practice Closure - The surgery will be closed from 1.00pm until 5.30pm on Tuesday 4th June for Staff Training. During this time we ask that patients contact 111 for any medically urgent concerns or 999 for life threatening issues.

Everest House Surgery

Everest Way, Hemel Hempstead, Herts, HP2 4HY

Telephone: 01442 500 164

Sorry, we're currently closed. Please call NHS 111

Online proxy access form

ONLINE ACCESS TO HEALTH RECORDS REQUEST

Name(Required)
Date of birth(Required)
Address

Section 2: Record requested

I wish to have access to the following online services (please tick all that apply):
I wish to access my medical record online and both understand and agree with each of the following statements (tick):
DD slash MM slash YYYY

Section 3: Consent to proxy access to GP Online Services (if patient has capacity)

Consent to proxy access to GP Online Services (if patient has capacity)
DD slash MM slash YYYY

I/We wish to have access to the health records on behalf of the above-named patient
Name
Date of birth
Address
Reason for access:

Section 4: Consent to proxy access to GP Online Services (if patient does not have capacity)

I/We wish to have access to the health records on behalf of the above-named patient
Name
Date of birth
Address
Reason for access:

Section 5: Proxy access online services available

I/We wish to have access to the following online services (please tick all that apply)

Section 6: Proxy declaration

I/We wish to access to the medical record online of the above patient and I/we understand and agree with each statement (tick)
DD slash MM slash YYYY

Section 7: Proof of identity

Under the Data Protection Act 2018, you do not have to give a reason for applying for access to your own health records. However, all applicants will be asked to provide two forms of identification, one of which must be photographic identification before access can be set up. Please speak to reception if you are unable to provide this.
Max. file size: 128 MB.
Max. file size: 128 MB.

ADDITIONAL NOTES

Incomplete applications will be returned; therefore, please ensure you have the correct documentation before returning the form.

Opening Times

  • Monday
    08:00am to 01:00pm
    02:00pm to 06:30pm
  • Tuesday
    08:00am to 01:00pm
    02:00pm to 06:30pm
  • Wednesday
    08:00am to 01:00pm
    02:00pm to 06:30pm
  • Thursday
    08:00am to 01:00pm
    02:00pm to 06:30pm
  • Friday
    08:00am to 01:00pm
    02:00pm to 06:30pm
  • Saturday
    CLOSED
  • Sunday
    CLOSED
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