Proxy Access to Patient Online Services

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

  • 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
  • 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.
  • Please enter the name of the patient whose online access you would like to manage.
  • DD slash MM slash YYYY
    Please enter the patient's date of birth using the calendar provided
  • Please enter the patient's phone number including dialing code
  • 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
  • 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.
  • Please enter your name as the proxy.
  • DD slash MM slash YYYY
    Please enter your date of birth using the calendar icon
  • Please enter your address.
  • Please enter your phone number including dialing code
  • Please enter an email, we will use this to send you the login details for Proxy access.
  • Please state your relationship to the patient. e.g. parent, child, carer etc.
  • 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
  • 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
    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.
  • 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 18 and cared for adults. Proxy for children under the age of 18 will only be approved if the child lives at the same address as the proxy and any queries will be investigated thoroughly. Once the child reaches 18 proxy will be automatically removed unless there is a reason for Proxy to be continued. The practice reserves the right to refuse proxy access where there is uncertainty over access rights.
  • This field is for validation purposes and should be left unchanged.