Online Services Proxy Consent Form

Proxy Access:

Proxy or third party access can be applied for with patient consent on this application form.

Online access may be granted for parents, carers or legal guardians to access children’s records under the age of 13.

Children aged 13 and over would be required to consent to proxy access to their records under General Data Protection Regulations.

If the patient does not have capacity to consent to 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.

Proxy access application will not be accepted from any third party commercial company i.e. Insurance company or solicitors.

This website is not monitored out of surgery hours so patients will not receive any response until service resumes. Please redirect requests to NHS 111 or your local pharmacy out of hours.

Consent to proxy access to GP online services

Consent to proxy access to GP online services

Patient Details

This is the person whose records are being accessed.
Please use date format DD/MM/YYYY
Please include postcode.

Representative's Details

These are the people seeking proxy access to the patients online records, appointments, or repeat prescription.

Representative 1

Please use date format DD/MM/YYYY
Please include postcode.

Representative 2

Please use date format DD/MM/YYYY.
Please include postcode.

Section 1 - For Patient

I give permission to my GP practice to give the following people, proxy access to my 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 - For Patient

Please indicate in the boxes by ticking which items are being applied for in this section: *

Section 3 - For Third Party/Carer

I/We wish to have online access to the services ticked in the box above in Section 2 for the patient stated above. 
 
I/We understand my/our responsibility for safeguarding sensitive medical information and I/We understand and agree with each of the following statements:
*
*
*
*

ID Verification

ID verification is required in person at the surgery reception to ensure access is granted to patients/proxy users that have a legitimate reason to access a record.

This will prevent access being granted to the wrong person and support the practice to adhere to stringent information security guidelines.

Please provide 2 documents as proof of identity with the proxy access application, one of which must contain a photograph.

Acceptable documents include passports, photo driving licences and bank statements. If none of the above are available, household bills may be accepted at the discretion of the Practice anagement.