Proxy Access Request

 

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Note: If the patient does not have capacity to consent to grant proxy access and proxy access is considered by the practice to be in the patient’s best interest section 1 of this form may be omitted.

Section 1
I give permission to my GP practice to give the following people proxy access to the online services as indicated below in section 2.
  • I reserve the right to reverse any decision I make in granting proxy access at any time.
  • I understand the risks of allowing someone else to have access to my health records.
  • I have read and understand the information leaflet provided by the practice
Section 2
Section 3
I/we wish to have online access to the services ticked in the box above in section 2 for

I/we understand my/our responsibility for safeguarding sensitive medical information and I/we understand and agree with each of the following statements:

Patient Details

This is the person whose records are being accessed

Representative 1 Personal Details

These are the people seeking proxy access to the patient’s online records, appointments or repeat prescription

Please double check you've entered the correct email address
Only following file extensions are allowed: jpg, jpeg, png, webp, pdf, doc, docx, pptx
Representative 2 Personal Details
Please double check you've entered the correct email address
Only following file extensions are allowed: jpg, jpeg, png, webp, pdf, doc, docx, pptx
Additional Information

Your Proxy Access Request will be reviewed by a member of the team and they will be in contact with you if they require more information regarding your request.

Privacy Consent

This form collects personal and medical information about you. We use this information to allow the practice team to contact you. Please read our Privacy Policy to discover how we protect and manage your submitted data.

 
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