Online Access for Proxy

Section 1 – Patient Details

(This is the person whose records are being accessed)

All responses we send will go to this email address.
Please confirm the folllowing: *

I give permission to my GP practice to give the people listed in Section 3 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 understood the information leaflet provided by the practice.

Section 2 – Details of access required

Please tick proxy access required:

Section 3 – Details of the representative(s) seeking proxy access

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

I/we wish to have online access to the services ticked above in Section 2 for the patient named in Section 1.

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

Representative 1
Representative 2