Proxy Access: Managing Another Person’s Health

Section 1: Your Details

The person requesting proxy access to patient online records, appointments or repeat prescriptions

Your Name(Required)

First name Last name

Your Date of Birth(Required)

Your NHS Number (if known)

Your Address(Required)

Address Line 1 Address Line 2 City Post Code

Your Phone Number(Required)

Your Email Address(Required)

Section 2: About the Patient

Let us know your relationship to the person you are requesting proxy access for, and why you want it.

What is your relationship to the patient?(Required)

Parent

Guardian

Other family member

Carer (informal/unpaid)

Carer (formal/paid)

Care home staff

Other

Reason for requesting proxy access(Required)

Section 3: Patient Details

Details of the person you are requesting proxy access for.

Patient Name(Required)

First name Last name

Date of Birth(Required)

Patient NHS Number (if known)

Patient Address(Required)

Address Line 1 Address Line 2 City Post Code

Patient Phone Number

If applicable

Patient Email Address

If applicable

Section 4: Patient Consent

If you are requesting proxy access for someone aged 13 or older who has capacity to make decisions, they need to give their consent.

Are you requesting proxy access for someone aged 13 or over?(Required)

Yes

No

Does the person have capacity to give consent(Required)

If the answer is no, we will make a decision on whether granting proxy access is in the patients best interest.

Yes

No

To be completed by Patient

I give permission to my GP practice to give the proxy access to my online services to those named in Section 1.

- 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.

I consent to those named in Section 1 being given proxy access to the following services.

Online Appointments Booking

Online Prescription Management

Full Medical Records

Patient Signature

Date

Section 5: Identity Verification

Verifying your identity online means we can process your request quicker.

If you cannot provide identity verification online, you will need come to the practice with the relevant documents.

We will contact you when we have processed your form.

Upload an ID document

Upload a photo of your passport, driving license or other official ID document.

Please make sure your photo is clear and relevant information can be read

Accepted file types: jpg, png, pdf, Max. file size: 512 MB.

Upload a Photograph of yourself

Take a photo of yourself using your phone or computer camera. In it you should be holding a piece of paper with today's date written in dd-mm-yy format

Please make sure your photo is clear and relevant information can be read

Accepted file types: jpg, png, pdf, Max. file size: 512 MB.

Confirmation(Required)

I confirm the information I have entered is accurate.

Your Signature(Required)

Date(Required)

CAPTCHA

Email

This field is for validation purposes and should be left unchanged.

Request for Proxy Access to online services

Section 1: Your Details

Section 2: About the Patient

Section 3: Patient Details

Section 4: Patient Consent

Section 5: Identity Verification