Care Home Staff - Springwood Surgery

Care home requests

Staff of care homes (and nursing homes) can order ad-hoc repeat prescription medication (interim medication) for care home residents that are patients of Springwood Surgery using the form below. Please do not use this form for monthly repeat prescription requests. Online services should be used for the ordering of monthly repeat prescriptions.

Interim Medication Request

Confirmation

I confirm I am a member of staff at the following care home

Name of care home

Belmont View

Gracelands

Guisborough Manor

Moorlands

Park House

Patient's forename

Patient's surname

Patient's date of birth

Medication(s) requiredPlease use the + symbol to add each additional medication to the list

Name (e.g. Paracetamol)

Dose (e.g. 500mg twice daily)

Quantity (e.g. x 14 or 7 days etc.)

Why are you requesting this medication?

Full name of staff member making the request

Email address of care home

Proxy access to online services

Registration For Access To Online Services For Care Home Staff (C1)

Confirmation

I confirm I am a member of staff at the following care home

Name of care home

Belmont View

Gracelands

Guisborough Manor

Moorlands

Park House

Details of care home worker requiring access to online services

Title

Mrs

Miss

Forename(s)

Surname

Date of birth

Proof of identification of care home worker requiring access to online services

To be completed by the care home manager on behalf of the care home worker. Please provide at least one proof of identification. If the proof provided is not a UK drivers licence or UK passport number please provide a copy of the photo ID;

UK Drivers Licence Optional

UK Passport Optional

Other photo ID Optional

Please upload photo ID Optional

Accepted file types: jpg, gif, png, pdf, Max. file size: 50 MB.

Terms of information sharing agreement

To be completed by the care home manager on behalf of the care home worker named above. The care home worker named above agrees (tick all to confirm) with each statement below with regards to accessing the online information of patients registered with Springwood Surgery that have consented to proxy access by care home staff

Acceptance of the terms of the information sharing agreement;

The care home worker named above has read and understood the information leaflet provided by Springwood Surgery about online access and will treat patient information as confidential

The care home worker named above will be responsible for the security of any of the information that they see or download

The care home worker named above will contact the practice as soon as possible if they suspect that their account has been accessed without their agreement

If the care home worker named above sees information in a patient record that is not about the patient or is inaccurate, they will contact the practice as soon as possible. They will treat this information as strictly confidential

Signature of care home manager

I confirm all information provided to be correct and I have verified the identity of the care home worker named above

Full name of care home manager

Date

Patient Consent For Proxy Access To Online Services For Care Home Staff (C2)

Confirmation

I confirm I am a member of staff at the following care home

Name of care home

Belmont View

Gracelands

Guisborough Manor

Moorlands

Park House

Details of patient consenting to proxy access of their online services

Forename(s)

Surname

Date of birth

Online services required

To be completed by the care home manager on behalf of the care home and all associated care home workers

Please select one or more online services;

Request medication on behalf of the patient named above

Book appointments on behalf of the patient named above

Terms of information sharing agreement

To be completed by the care home manager on behalf of the care home and all associated care home workers. I/we understand and agree (tick to confirm) with each statement below with regards to the online information of the patient named above

Acceptance of the terms of the information sharing agreement;

I/we have read and understood the information leaflet provided by the practice about online access and will treat the patient’s information as confidential

I/we will be responsible for the security of any of the information that I/we see or download

I/we will contact the practice as soon as possible if I/we suspect that the account has been accessed without my/our agreement

If I/we see information in the record that is not about the patient or is inaccurate, I/we will contact the practice as soon as possible. I/we will treat this information as strictly confidential

Consent

To be completed by the care home manager on behalf of the care home and all associated care home workers

Please choose from one of the following statements;

I am requesting access to the online services of the patient named above and I have informed the patient and provided information about how they can object. The patient has consented

I am requesting access to the online services of the patient named above and the patient’s next of kin or legal power of attorney has consented based on the best interests for the patient

I am requesting access to the online services of the patient named above. I am requesting this access based on the best interests for the patient and a next of kin or legal power of attorney is unavailable to consent on behalf of the patient

Signature of care home managerI confirm all information provided to be correct and I have verified the identity of the patient named above

Full name of care home manager

Date

Care home requests

Interim Medication Request

Proxy access to online services

Registration For Access To Online Services For Care Home Staff (C1)

Details of care home worker requiring access to online services

Proof of identification of care home worker requiring access to online services

Terms of information sharing agreement

Patient Consent For Proxy Access To Online Services For Care Home Staff (C2)

Details of patient consenting to proxy access of their online services

Online services required

Terms of information sharing agreement

Consent

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