Proxy Access

Online Access Patient Information

Section 1

I give permission to my GP practice to give proxy access to the online services to the individuals names below *

Yes No

Name of individuals to receive access *

I reserve the right to reverse any action I make in granting proxy access at any time. *

Yes No

I understand the risks of allowing someone else to have access to my health records. *

Yes No

I have read and understand the online access patient information above provided by the practice *

Yes No

date *

Section 2

To be completed by the patient

I wish to have access to (Please be aware that some of the below services may not be available *

Online appointment booking

Online prescription management

Access the medical record for the patient in Section 4

Section 3

To be completed by the representatives

Section 4

The Patient - (this is the person whose records are being accessed.)

The representatives

These are the people seeking proxy access to the patients online records, appointments or repeat presctiption

Full name *

Date of birth *

Address *

Email address *

Phone number *

Relationship to patient *

Carer

Care home

Mother

Father

Friend

Other family member

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 tream 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.

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