Register for online services on behalf of someone else (Proxy Access)

Register for online services on behalf of someone else (Proxy Access)

Section 1 (to be completed by the patient)

I give permission to my GP practice to give proxy access to the online services (as indicated below in Section 2) to the individuals named below
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 online access patient information above provided by the practice.
DD slash MM slash YYYY

Section 2 (to be completed by the patient)

I wish to have access to:
Please be aware that some of the above services may not be available.

Section 3 (to be completed by the representatives)

I/we wish to have online access to the services ticked in the box above in Section 2 for the patient in Section 4.

I/We understand my/our responsibility for safeguarding sensitive medical information and I/we understand and agree with each of the following statements:
I/we have read and understood the online access patient information above provided by the practice and agree that I/we will treat the patient information as confidential
I/we will be responsible for the security of the information that I/we see or download
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
DD slash MM slash YYYY

Section 4 The Patient – (This is the person whose records are being accessed)

Name
DD slash MM slash YYYY
Please use format day/month/year e.g. 12/05/1979
Address

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

Name
DD slash MM slash YYYY
Please use format day/month/year e.g. 12/05/1979
Address
Relationship to patient

Verify your identity

For verification purposes, to complete your registration you will need to attach two forms of identification to the form below. One form of photo ID (passport, driving licence) and one from of proof of address (utility bill, bank statement).
Max. file size: 1 GB.

Privacy Policy

This form collects your name, date of birth, email, other personal information and medical details. This is to confirm you are registered with the practice, to allow the practice team to contact you and also to update your medical records held by the practice and our partners in the NHS. Please read our Privacy Policy to discover how we protect and manage your submitted data.
Your consent