Proxy access request to online services

Once the form below is completed and submitted please email us copies of your proof of ID and address to: [email protected]

Please note this is a limited email address and cannot be used for medical requests or general enquiries.

Section 1: Patient details

Details of the patient for whom the request relates
Title(Required)

Date of birth(Required)
Email address

Section 2: Representative (proxy) person details

Please provide the following information about the proxy.
Title(Required)

Date of birth(Required)
Email(Required)

Section 3: Legal basis for request

Please provide the basis for this request.
Legal basis for proxy access(Required)

Section 4: Which online services do you wish to grant access to?

The representative stated on this form, is allowed proxy access to the following services:
I wish to grant / have access to the following online services(Required)
Please tick all that apply

Section 5: Patient's consent

Patient's consent(Required)

Section 6: Representative (proxy) consent

Representative (proxy) consent(Required)

Signature of patient or representative (proxy)

Today's date(Required)
Not for urgent medical help(Required)
Representative (proxy) identity(Required)
To register for Online Services Proxy Access we need to verify the representative's identity. Please provide the practice: One photo ID such as passport or drivers licence and one form of ID with your home address on such as a recent utility bill or bank statement.
Consent(Required)

Date published: 15th December, 2023
Date last updated: 19th January, 2024