Online services proxy access request form

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

Details of the Patient

Title: *

Full Name: *

Date of Birth: *

Email Address: * *

Phone Number: *

Representative (proxy) person details

Please provide the following information about the proxy.

Title: *

Relationship to individual stated in Section 1 above *

First name: *

Surname: *

Date of Birth:

Address: *

Postcode: *

Email: *

Contact Number: *

Do you need to add a second applicant?: *

Yes No

Legal basis for request

Please provide the basis for this request.

Legal basis for proxy access *

Parental responsibility for a patient under 16 years

Lasting Power of Attorney

Carer or Guardian

Other

Which online services do you wish to grant access to?

The representative stated on this form, is allowed proxy access to the following services:

I wish to grant / have access to the following online services

Booking Appointments:

Requesting Repeat Prescriptions:

Access to Medical Records:

Access to Test Results:

Patient's consent

Patient's consent

I understand that this consent will remain in force indefinitely. However, my doctor may, at my request, override this authority to allow access to my medical records via the Patient Access/Online Services at any time.

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 medical records.

Representative (proxy) consent

Representative (proxy) consent *

I will treat any information provided confidentially.

I will not disclose information to a third party without agreement.

I will only use the information in the person that I have proxy access for in their best interest.

Signature of patient or representative (proxy)

Please enter your full name below *

Date *

Not for urgent medical help *

Yes, I understand this form is not for urgent medical help

Representative (proxy) identity

To register for Online Services Proxy Access we need to verify the representative's identity. Please provide the practice: One photo ID such as passport or drivers licence and one form of ID with your home address on such as a recent utility bill or bank statement.

Yes I understand - I will send the practice the required ID to complete my online registration for proxy access.

Supporting documents

We require evidence of your ID or Birth Certificate

Please email a copy your supporting documents to our practice email:

DOCMANEDT.G85673@NHS.NET

Consent

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 7 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.

I agree to the privacy policy.

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Online services proxy access request form

Online services proxy access request form

Further Information