Proxy Access to Patient Online Services

Please complete the form carefully to ensure that we can process your request efficiently.

**Is the patient under 16years** (Yes/No)*
If you/they are allowing proxy access to their medical record over the age of 16, consent will ONLY be approved in written form and online requests WILL be declined due to this form being completed incorrectly against GDPR.
Section 1
If the patient does not have the capacity to consent to grant proxy access and proxy access is considered, by that practice, to be in the patient's best interest, please move directly to section 2
To be completed by the Patient: Patient's full name
By entering your full name you reserve the right to reverse any decision you make in granting proxy access at any time. You understand the risks of allowing someone else to access your health records.
Section 2
Section 2 should be completed by the patient, where possible. The information provided will be matched with the patient records and any discrepancies may lead to a refusal of proxy access.
Name of Patient*
First Last
Please enter the name of the patient whose online access you would like to manage.
Patient's Date of Birth*
DD slash MM slash YYYY

Please enter the patient's date of birth using the calendar provided
Patient's address*
Street Address Address Line 2 Town/City County Postcode
Patient's Phone number*
Please enter the patient's phone number including dialing code
Patient's ID 1*
Accepted file types: jpg, jpeg, png, pdf, Max. file size: 5 MB.
The identity of the patient must be verified for Proxy to be processed. Please upload a clear photo of the following: 1. Birth Certificate AND a copy of a utility bill to show proof of address OR 2. Photo ID driving license OR 3. Passport AND a copy of a utility bill to show proof of address
Patient's ID 2
Accepted file types: jpg, jpeg, png, pdf, Max. file size: 5 MB.
The identity of the patient must be verified for Proxy to be processed. Please upload a clear photo of the following: 1. Birth Certificate AND a copy of a utility bill to show proof of address OR 2. Photo ID driving license OR 3. Passport AND a copy of a utility bill to show proof of address
Section 3
The Proxy must complete section 3. The proxy is the person seeking access to the patient's online records, appointments or repeat prescription.
Name of Proxy*
First Last
Please enter your name as the proxy.
Date of Birth of Proxy*
DD slash MM slash YYYY

Please enter your date of birth using the calendar icon
Address of Proxy*
Street Address Address Line 2 Town/City County Postcode
Please enter your address.
Phone number of Proxy*
Please enter your phone number including dialing code
Email of Proxy*
Enter Email Confirm Email
Please enter an email, we will use this to send you the login details for Proxy access.
Relation of Proxy to Patient*
Please state your relationship to the patient. e.g. parent, child, carer etc.
Proxy ID 1*
Accepted file types: jpg, jpeg, png, pdf, Max. file size: 5 MB.
To verify your identity as Proxy you must upload a photo of the following: 1. Birth Certificate AND a copy of a utility bill to show proof of address OR 2. Photo ID driving license OR 3. Passport AND a copy of a utility bill to show proof of address
Proxy ID 2
Accepted file types: jpg, jpeg, png, pdf, Max. file size: 5 MB.
To verify your identity as Proxy you must upload a photo of the following: 1. Birth Certificate AND a copy of a utility bill to show proof of address OR 2. Photo ID driving license OR 3. Passport AND a copy of a utility bill to show proof of address
Terms and Conditions*
- Please tick this box
By ticking this box you have read and understood the following terms and conditions: You will be responsible for the security of the information that you see or download. You will contact the practice as soon as possible if you suspect that the account has been accessed by someone without your agreement. If you see information in the record that is not about the patient, or is inaccurate, you will contact the practice as soon as possible. You will treat any information which is not about the patient as being strictly confidential. If proxy access is requested for anyone under the age of 16 is granted, rights will automatically be removed once they reach 16 years of age. If they are wanting to continue proxy access this needs to be in written from on or after their 16th birthday.
Initials and today's date*
By entering your initials and today's date you have electronically signed this document and consent to the form being processed by the practice. The practice will contact yourself and/or the patient to verify that this is a consented proxy for any children over the age of 16 and cared for adults. Proxy for children under the age of 16 will only be approved if the child lives at the same address as the proxy and any queries will be investigated thoroughly. The practice reserves the right to refuse proxy access where there is uncertainty over access rights.
Consent*
I agree to the privacy policy.
By submitting your details you are consenting to providing this information for improving our services to you. The data you supply on this form will be securely stored on our website, which is hosted by a third party. We will retain this information on the website for no longer than 14 calendar days. your contact details will not be sold or shared with a third party. I understand I can revoke this consent at anytime by contacting the practice. Our privacy policy can be viewed on this website.
Phone
This field is for validation purposes and should be left unchanged.

Section 1

Section 2

Section 3

Helpful links

Further Info