Requesting Proxy Access

Proxy Access allows a patient to grant another person access to their online records. This could be a family member, carer, or next of kin. For further information on Proxy Access, please click here.

If you wish to apply for Proxy Access, please complete the following form.

Proxy Access Consent Form

The Patient

(The person whose records another individual(s) is to be given access to)

Name

First Last

Date of Birth

Gender

Male

Female

Address

Street Address Address Line 2 City Postcode

Phone Number

Details of person to be given access to this patient’s information

Name

First Last

Address

Street Address Address Line 2 City Postcode

Relationship to Patient

Is this access going to be limited in anyway?

Yes

If 'Yes', please specify limitations Optional

Prof of ID and Address

Drop files here or

Max. file size: 1 GB.

Please upload prof of your ID and prof of address

I confirm that I give permission for the Practice to communicate with the person identified above in regards to my medical records.

Your Signature

Date

Proxy Access Consent Form

The Patient

Details of person to be given access to this patient’s information

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