Register for Proxy Online Access (to another patient's record)

Once we receive your completed form a member of the team will contact you to verify your identification and any other details as necessary. Proxy access is only granted at the GP's discretion

Last Updated: 04/08/2022

  • The Patient

    This is the person whose records are being accessed

    Does the patient have capacity to consent to proxy online access to their medical record?
    Date of Birth
    For example, 15 3 1984

  • The Representative

    This is the person seeking proxy access to the patient's online appointments, repeat prescriptions or coded medical records

    Date of Birth
    For example, 15 3 1984
    I understand that It is my responsibility to keep my account secure by keeping my details confidential I understand that I can terminate my account at any time by contacting the surgery, and that this form will be kept on my electronic records.
    I understand and agree with the following statements: I will treat the patient information as confidential. I will be responsible for the security of the information that I see or download. I 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. I will treat any information which is not about the patient as being strictly confidential.
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