Online access proxy request

Fill in the form below to request proxy access for online services.

"*" indicates required fields

Section 1

Proxy access consent*
I, the patient, give permission to my GP practice to give the following person 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

I (the patient) consent to give proxy access to the following online services (please tick all that apply):*

Section 3

Proxy access agreement*
Safeguarding agreement*
I have read and understood the information leaflet provided by the practice and agree that I will treat the patient information as confidential. I will be responsible for the security of the information that I see or download. I understand we may read some information that could be unexpected or upsetting. I will contact the practice as soon as possible if I suspect that the account has been accessed by someone without my agreement. If I see information in the record that is not about the patient, or is inaccurate, I will contact the practice as soon as possible. I will treat any information which is not about the patient as being strictly confidential.

Patient details

(This is the person whose records are being accessed)
Date of birth*

Representative details

(The person seeking proxy access to the patient’s online records, appointments or repeat prescription.)
Date of birth*
Legal basis reason for proxy access*

Consent

Consent*
Not for urgent medical help*

Date published: 7th March, 2023
Date last updated: 9th March, 2023