To register for proxy access to our online services, you will need to complete this form.
We will then issue you with a username and password.
Required field(s) are indicated by *
Proxy Access to GP Online Services
Personal Details
The patient (to be completed by the child where age permits). This is the person whose records are being accessed.
First Name: *
Surname: *
Date of Birth: *
Telephone Number:
Email Address: *
Postcode: *
Address: *
Patient Consent
I have read and understood the following conditions: *
I give permission to my GP practice to give the following person proxy access to the online services as indicated in section 3.
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.
Signature: *
Date:
Online Services
The representative. This is the person seeking proxy access to the patient's online records, appointments or prescriptions.
I wish to have access to the following online services (Please select all that apply):
Online Prescription Management
Accessing the Medical Records
Representative Consent (Section 3):
The representative. This is the person seeking proxy access to the patient's online records, appointments or prescriptions.
I understand that my responsibility for safeguarding sensitive medical information and understand and agree with each of the following statements: *
I have read and understood the information leaflet provided by the practice.
I will be responsible for the security of the information that I see or download will contact the practice as soon as possible if I suspect that the account has been accessed by someone without my/our agreement.
If I see information in the record that is not about the patient, or is inaccurate, I will contact the practice as soon as possible.
Representative Signature: *
Relationship to Patient: *
Signature of Patient if over 11:
Please tick next to the most relevant statement:
Named on Birth Certificate
Granted parental rights by the courts
Main Carer
Father, you were married to the mother at the time of birth
Father, you have the agreement of the mother
Proof may be required to indicate that parental rights have not been removed by the courts.
Personal Details (The Representative)
The representative. This is the person seeking proxy access to the patient's online records, appointments or prescriptions.
First Name: *
Surname: *
Date of Birth: *
Telephone Number:
Mobile Number:
Postcode: *
Email Address: *
Address: *
Personal Details (The Representative)
The representative. This is the person seeking proxy access to the patient's online records, appointments or prescriptions.