Request Proxy Access to GP online services

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.

If you are making a proxy access aplication to access the medical records of a child, we will need to see evidence of parental responsiblity.

Last Updated: 05/01/2024

Section 1

I ( named in below) 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 informtion leaflet provided by the practice.

Your Full Name *

Full Name of people you are giving proxy access to *

Section 2

Please tick one or more of what online services you would like to share. *

Online prescription management

Appointment management (will be coming soon)

Access to detailed coded records

Access to prospective full records

Section 3

I/we.... (names of representatives) wish to have online access to the services ticked in the box above section 2

for.... (name of patient)

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

Name of representatives *

Name of patient *

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

I/we have read and understood the information leaflet provided by the practice and agree that I will treated the patient information as confidential

I/we will be responsible for the security of the information that I/we see or downloaded.

I/we will contact the practice as soon as possible if I/we suspect that the account has been accessed by someone without my/our agreement

If I/we see information in the record that is not about the patient, or is inaccurate, I/we will contact the practice as soon as possible. I will treat any information which is not about the patient as being strictly confidential.

Signature/s of Carer or Relative *

Today's Date *

Relationship to patient *

The Patient

This is the person whose records are being accessed

Surname *

First Name *

Date of Birth *

Address *

Postcode *

Email Address *

Telephone Number *

Mobile Number *

Signature of Patient *

Today's Date *

This form is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.

Request Proxy Access to GP online services

Further Information