{"id":3971,"date":"2025-01-24T12:41:16","date_gmt":"2025-01-24T12:41:16","guid":{"rendered":"https:\/\/digitalfirstgp.com\/base-gp-practice\/?post_type=resources&#038;p=3971"},"modified":"2025-01-24T12:44:34","modified_gmt":"2025-01-24T12:44:34","slug":"proxy-access-managing-another-persons-health","status":"publish","type":"resources","link":"https:\/\/digitalfirstgp.com\/base-gp-practice\/Resources\/proxy-access-managing-another-persons-health\/","title":{"rendered":"Proxy Access: Managing Another Person&#8217;s Health"},"content":{"rendered":"<script type=\"text\/javascript\">var gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,initializeOnLoaded:function(o){gform.domLoaded&&gform.scriptsLoaded?o():!gform.domLoaded&&gform.scriptsLoaded?window.addEventListener(\"DOMContentLoaded\",o):document.addEventListener(\"gform_main_scripts_loaded\",o)},hooks:{action:{},filter:{}},addAction:function(o,n,r,t){gform.addHook(\"action\",o,n,r,t)},addFilter:function(o,n,r,t){gform.addHook(\"filter\",o,n,r,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,n){gform.removeHook(\"action\",o,n)},removeFilter:function(o,n,r){gform.removeHook(\"filter\",o,n,r)},addHook:function(o,n,r,t,i){null==gform.hooks[o][n]&&(gform.hooks[o][n]=[]);var e=gform.hooks[o][n];null==i&&(i=n+\"_\"+e.length),gform.hooks[o][n].push({tag:i,callable:r,priority:t=null==t?10:t})},doHook:function(n,o,r){var t;if(r=Array.prototype.slice.call(r,1),null!=gform.hooks[n][o]&&((o=gform.hooks[n][o]).sort(function(o,n){return o.priority-n.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==n?t.apply(null,r):r[0]=t.apply(null,r)})),\"filter\"==n)return r[0]},removeHook:function(o,n,t,i){var r;null!=gform.hooks[o][n]&&(r=(r=gform.hooks[o][n]).filter(function(o,n,r){return!!(null!=i&&i!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][n]=r)}});<\/script>\n                <div class='gf_browser_gecko gform_wrapper gravity-theme' id='gform_wrapper_8' style='display:none'><div id='gf_8' class='gform_anchor' tabindex='-1'><\/div>\n                        <div class='gform_heading'>\n                            <h2 class=\"gform_title\">Request for Proxy Access to online services<\/h2>\n                            <span class='gform_description'><p>This form can be used to request proxy access to another patients medical records.<\/p>\r\n\r\n<p>Online access may be granted for parents, carers or legal guardians to access children\u2019s records under the age of 13.<\/p>\r\n\r\n<strong><p>Children aged 13 and over are required to consent to proxy access to their records under General Data Protection Regulations.<\/p><\/strong>\r\n\r\n<p>Proxy access applications will not be accepted from any third party commercial company i.e. Insurance company or solicitors.<\/p><\/span>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_8'  action='\/base-gp-practice\/wp-json\/wp\/v2\/resources\/3971#gf_8' novalidate>\n        <div id='gf_progressbar_wrapper_8' class='gf_progressbar_wrapper'>\n        \t<p class=\"gf_progressbar_title\">Step <span class='gf_step_current_page'>1<\/span> of <span class='gf_step_page_count'>5<\/span>\n        \t<\/p>\n            <div class='gf_progressbar gf_progressbar_blue' aria-hidden='true'>\n                <div class='gf_progressbar_percentage percentbar_blue percentbar_20' style='width:20%;'><span>20%<\/span><\/div>\n            <\/div><\/div>\n                        <div class='gform_body gform-body'><div id='gform_page_8_1' class='gform_page' >\n                                    <div class='gform_page_fields'><div id='gform_fields_8' class='gform_fields top_label form_sublabel_below description_above'><div id=\"field_8_5\"  class=\"gfield gsection field_sublabel_below field_description_above gfield_visibility_visible\"  data-js-reload=\"field_8_5\"><h3 class=\"gsection_title\">Section 1: Your Details<\/h3><div class='gsection_description' id='gfield_description_8_5'>The person requesting proxy access to patient online records, appointments or repeat prescriptions<\/div><\/div><fieldset id=\"field_8_6\"  class=\"gfield gfield--width-full gfield_contains_required field_sublabel_below field_description_above gfield_visibility_visible\"  data-js-reload=\"field_8_6\"><legend class='gfield_label gfield_label_before_complex'  >Your Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_complex ginput_container no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name' id='input_8_6'>\n                            \n                            <span id='input_8_6_3_container' class='name_first' >\n                                                    <input type='text' name='input_6.3' id='input_8_6_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_8_6_3' >First name<\/label>\n                                                <\/span>\n                            \n                            <span id='input_8_6_6_container' class='name_last' >\n                                                    <input type='text' name='input_6.6' id='input_8_6_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_8_6_6' >Last name<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><fieldset id=\"field_8_7\"  class=\"gfield gfield--width-full gf_left_half gfield--width-half gfield_contains_required field_sublabel_below field_description_above gfield_visibility_visible\"  data-js-reload=\"field_8_7\"><legend class='gfield_label gfield_label_before_complex'  >Your Date of Birth<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div id='input_8_7' class='ginput_container ginput_complex'>\n                                        <div class='gfield_date_day ginput_container ginput_container_date' id='input_8_7_2_container'>\n                                            <input type='number'  name='input_7[]' id='input_8_7_2' value=''   aria-required='true'   placeholder='DD' min='1' max='31' step='1'\/>\n                                            <label for='input_8_7_2' class='screen-reader-text'>Day<\/label>\n                                        <\/div><div class='gfield_date_month ginput_container ginput_container_date' id='input_8_7_1_container'>\n                                        <input type='number'  name='input_7[]' id='input_8_7_1' value=''   aria-required='true'   placeholder='MM' min='1' max='12' step='1'\/>\n                                        <label for='input_8_7_1' class='screen-reader-text'>Month<\/label>\n                                   <\/div><div class='gfield_date_year ginput_container ginput_container_date' id='input_8_7_3_container'>\n                                        <input type='number'  name='input_7[]' id='input_8_7_3' value=''   aria-required='true'   placeholder='YYYY' min='1920' max='2027' step='1'\/>\n                                        <label for='input_8_7_3' class='screen-reader-text'>Year<\/label>\n                                   <\/div>\n                                <\/div><\/fieldset><div id=\"field_8_45\"  class=\"gfield gfield--width-full gf_right_half gfield--width-half field_sublabel_below field_description_above gfield_visibility_visible\"  data-js-reload=\"field_8_45\"><label class='gfield_label' for='input_8_45' >Your NHS Number (if known)<\/label><div class='ginput_container ginput_container_text'><input name='input_45' id='input_8_45' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_8_8\"  class=\"gfield gfield--width-full gfield_contains_required field_sublabel_below field_description_above gfield_visibility_visible\"  data-js-reload=\"field_8_8\"><legend class='gfield_label gfield_label_before_complex'  >Your Address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_zip ginput_container_address' id='input_8_8' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1' id='input_8_8_1_container' >\n                                        <input type='text' name='input_8.1' id='input_8_8_1' value=''    aria-required='true'    \/>\n                                        <label for='input_8_8_1' id='input_8_8_1_label' >Address Line 1<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2' id='input_8_8_2_container' >\n                                        <input type='text' name='input_8.2' id='input_8_8_2' value=''     aria-required='false'   \/>\n                                        <label for='input_8_8_2' id='input_8_8_2_label' >Address Line 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city' id='input_8_8_3_container' >\n                                    <input type='text' name='input_8.3' id='input_8_8_3' value=''    aria-required='true'    \/>\n                                    <label for='input_8_8_3' id='input_8_8_3_label' >City<\/label>\n                                 <\/span><input type='hidden' class='gform_hidden' name='input_8.4' id='input_8_8_4' value=''\/><span class='ginput_right address_zip ginput_address_zip' id='input_8_8_5_container' >\n                                    <input type='text' name='input_8.5' id='input_8_8_5' value=''    aria-required='true'    \/>\n                                    <label for='input_8_8_5' id='input_8_8_5_label' >Post Code<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_8.6' id='input_8_8_6' value='' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><div id=\"field_8_18\"  class=\"gfield gfield--width-full gf_left_half gfield--width-half gfield_contains_required field_sublabel_below field_description_above gfield_visibility_visible\"  data-js-reload=\"field_8_18\"><label class='gfield_label' for='input_8_18' >Your Phone Number<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_18' id='input_8_18' type='tel' value='' class='large'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_8_9\"  class=\"gfield gfield--width-full gf_right_half gfield--width-half gfield_contains_required field_sublabel_below field_description_above gfield_visibility_visible\"  data-js-reload=\"field_8_9\"><label class='gfield_label' for='input_8_9' >Your Email Address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_9' id='input_8_9' type='email' value='' class='large'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                         <input type='button' id='gform_next_button_8_41' class='gform_next_button button' value='Next'  onclick='jQuery(\"#gform_target_page_number_8\").val(\"2\");  jQuery(\"#gform_8\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_8\").val(\"2\");  jQuery(\"#gform_8\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_8_2' class='gform_page' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_8_2' class='gform_fields top_label form_sublabel_below description_above'><div id=\"field_8_38\"  class=\"gfield gsection field_sublabel_below field_description_above gfield_visibility_visible\"  data-js-reload=\"field_8_38\"><h3 class=\"gsection_title\">Section 2: About the Patient<\/h3><div class='gsection_description' id='gfield_description_8_38'>Let us know your relationship to the person you are requesting proxy access for, and why you want it.<\/div><\/div><fieldset id=\"field_8_39\"  class=\"gfield gfield--width-full gfield_contains_required field_sublabel_below field_description_above gfield_visibility_visible\"  data-js-reload=\"field_8_39\"><legend class='gfield_label'  >What is your relationship to the patient?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_8_39'>\n\t\t\t<div class='gchoice gchoice_8_39_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_39' type='radio' value='Parent'  id='choice_8_39_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_8_39_0' id='label_8_39_0'>Parent<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_8_39_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_39' type='radio' value='Guardian'  id='choice_8_39_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_8_39_1' id='label_8_39_1'>Guardian<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_8_39_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_39' type='radio' value='Other family member'  id='choice_8_39_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_8_39_2' id='label_8_39_2'>Other family member<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_8_39_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_39' type='radio' value='Carer (informal\/unpaid)'  id='choice_8_39_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_8_39_3' id='label_8_39_3'>Carer (informal\/unpaid)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_8_39_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_39' type='radio' value='Carer (formal\/paid)'  id='choice_8_39_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_8_39_4' id='label_8_39_4'>Carer (formal\/paid)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_8_39_5'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_39' type='radio' value='Care home staff'  id='choice_8_39_5' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_8_39_5' id='label_8_39_5'>Care home staff<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_8_39_6'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_39' type='radio' value='gf_other_choice'  id='choice_8_39_6' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_8_39_6' id='label_8_39_6'>Other<\/label><br \/><input id='input_8_39_other' name='input_39_other' type='text' value='Other' aria-label='Other Choice, please specify'  disabled='disabled' \/>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_8_40\"  class=\"gfield gfield--width-full gfield_contains_required field_sublabel_below field_description_above gfield_visibility_visible\"  data-js-reload=\"field_8_40\"><label class='gfield_label' for='input_8_40' >Reason for requesting proxy access<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_40' id='input_8_40' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_8_42' class='gform_previous_button button' value='Previous'  onclick='jQuery(\"#gform_target_page_number_8\").val(\"1\");  jQuery(\"#gform_8\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_8\").val(\"1\");  jQuery(\"#gform_8\").trigger(\"submit\",[true]); } ' \/> <input type='button' id='gform_next_button_8_42' class='gform_next_button button' value='Next'  onclick='jQuery(\"#gform_target_page_number_8\").val(\"3\");  jQuery(\"#gform_8\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_8\").val(\"3\");  jQuery(\"#gform_8\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_8_3' class='gform_page' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_8_3' class='gform_fields top_label form_sublabel_below description_above'><div id=\"field_8_12\"  class=\"gfield gsection field_sublabel_below field_description_above gfield_visibility_visible\"  data-js-reload=\"field_8_12\"><h3 class=\"gsection_title\">Section 3: Patient Details<\/h3><div class='gsection_description' id='gfield_description_8_12'>Details of the person you are requesting proxy access for.<\/div><\/div><fieldset id=\"field_8_13\"  class=\"gfield gfield--width-full gfield_contains_required field_sublabel_below field_description_above gfield_visibility_visible\"  data-js-reload=\"field_8_13\"><legend class='gfield_label gfield_label_before_complex'  >Patient Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_complex ginput_container no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name' id='input_8_13'>\n                            \n                            <span id='input_8_13_3_container' class='name_first' >\n                                                    <input type='text' name='input_13.3' id='input_8_13_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_8_13_3' >First name<\/label>\n                                                <\/span>\n                            \n                            <span id='input_8_13_6_container' class='name_last' >\n                                                    <input type='text' name='input_13.6' id='input_8_13_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_8_13_6' >Last name<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><fieldset id=\"field_8_14\"  class=\"gfield gfield--width-full gf_left_half gfield--width-half gfield_contains_required field_sublabel_below field_description_above gfield_visibility_visible\"  data-js-reload=\"field_8_14\"><legend class='gfield_label gfield_label_before_complex'  >Date of Birth<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div id='input_8_14' class='ginput_container ginput_complex'>\n                                        <div class='gfield_date_day ginput_container ginput_container_date' id='input_8_14_2_container'>\n                                            <input type='number'  name='input_14[]' id='input_8_14_2' value=''   aria-required='true'   placeholder='DD' min='1' max='31' step='1'\/>\n                                            <label for='input_8_14_2' class='screen-reader-text'>Day<\/label>\n                                        <\/div><div class='gfield_date_month ginput_container ginput_container_date' id='input_8_14_1_container'>\n                                        <input type='number'  name='input_14[]' id='input_8_14_1' value=''   aria-required='true'   placeholder='MM' min='1' max='12' step='1'\/>\n                                        <label for='input_8_14_1' class='screen-reader-text'>Month<\/label>\n                                   <\/div><div class='gfield_date_year ginput_container ginput_container_date' id='input_8_14_3_container'>\n                                        <input type='number'  name='input_14[]' id='input_8_14_3' value=''   aria-required='true'   placeholder='YYYY' min='1920' max='2027' step='1'\/>\n                                        <label for='input_8_14_3' class='screen-reader-text'>Year<\/label>\n                                   <\/div>\n                                <\/div><\/fieldset><div id=\"field_8_46\"  class=\"gfield gfield--width-full gf_right_half gfield--width-half field_sublabel_below field_description_above gfield_visibility_visible\"  data-js-reload=\"field_8_46\"><label class='gfield_label' for='input_8_46' >Patient NHS Number (if known)<\/label><div class='ginput_container ginput_container_text'><input name='input_46' id='input_8_46' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_8_16\"  class=\"gfield gfield--width-full gfield_contains_required field_sublabel_below field_description_above gfield_visibility_visible\"  data-js-reload=\"field_8_16\"><legend class='gfield_label gfield_label_before_complex'  >Patient Address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_zip ginput_container_address' id='input_8_16' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1' id='input_8_16_1_container' >\n                                        <input type='text' name='input_16.1' id='input_8_16_1' value=''    aria-required='true'    \/>\n                                        <label for='input_8_16_1' id='input_8_16_1_label' >Address Line 1<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2' id='input_8_16_2_container' >\n                                        <input type='text' name='input_16.2' id='input_8_16_2' value=''     aria-required='false'   \/>\n                                        <label for='input_8_16_2' id='input_8_16_2_label' >Address Line 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city' id='input_8_16_3_container' >\n                                    <input type='text' name='input_16.3' id='input_8_16_3' value=''    aria-required='true'    \/>\n                                    <label for='input_8_16_3' id='input_8_16_3_label' >City<\/label>\n                                 <\/span><input type='hidden' class='gform_hidden' name='input_16.4' id='input_8_16_4' value=''\/><span class='ginput_right address_zip ginput_address_zip' id='input_8_16_5_container' >\n                                    <input type='text' name='input_16.5' id='input_8_16_5' value=''    aria-required='true'    \/>\n                                    <label for='input_8_16_5' id='input_8_16_5_label' >Post Code<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_16.6' id='input_8_16_6' value='' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><div id=\"field_8_10\"  class=\"gfield gfield--width-full gf_left_half gfield--width-half field_sublabel_below field_description_above gfield_visibility_visible\"  data-js-reload=\"field_8_10\"><label class='gfield_label' for='input_8_10' >Patient Phone Number<\/label><div class='gfield_description' id='gfield_description_8_10'>If applicable<\/div><div class='ginput_container ginput_container_phone'><input name='input_10' id='input_8_10' type='tel' value='' class='large'    aria-invalid=\"false\" aria-describedby=\"gfield_description_8_10\"  \/><\/div><\/div><div id=\"field_8_17\"  class=\"gfield gfield--width-full gf_right_half gfield--width-half field_sublabel_below field_description_above gfield_visibility_visible\"  data-js-reload=\"field_8_17\"><label class='gfield_label' for='input_8_17' >Patient Email Address<\/label><div class='gfield_description' id='gfield_description_8_17'>If applicable<\/div><div class='ginput_container ginput_container_email'>\n                            <input name='input_17' id='input_8_17' type='email' value='' class='large'     aria-invalid=\"false\" aria-describedby=\"gfield_description_8_17\" \/>\n                        <\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_8_43' class='gform_previous_button button' value='Previous'  onclick='jQuery(\"#gform_target_page_number_8\").val(\"2\");  jQuery(\"#gform_8\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_8\").val(\"2\");  jQuery(\"#gform_8\").trigger(\"submit\",[true]); } ' \/> <input type='button' id='gform_next_button_8_43' class='gform_next_button button' value='Next'  onclick='jQuery(\"#gform_target_page_number_8\").val(\"4\");  jQuery(\"#gform_8\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_8\").val(\"4\");  jQuery(\"#gform_8\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_8_4' class='gform_page' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_8_4' class='gform_fields top_label form_sublabel_below description_above'><div id=\"field_8_20\"  class=\"gfield gsection field_sublabel_below field_description_above gfield_visibility_visible\"  data-js-reload=\"field_8_20\"><h3 class=\"gsection_title\">Section 4: Patient Consent<\/h3><div class='gsection_description' id='gfield_description_8_20'>If you are requesting proxy access for someone aged 13 or older who has capacity to make decisions, they need to give their consent.<\/div><\/div><fieldset id=\"field_8_24\"  class=\"gfield gfield--width-full gfield_contains_required field_sublabel_below field_description_above gfield_visibility_visible\"  data-js-reload=\"field_8_24\"><legend class='gfield_label'  >Are you requesting proxy access for someone aged 13 or over?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_8_24'>\n\t\t\t<div class='gchoice gchoice_8_24_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_24' type='radio' value='Yes'  id='choice_8_24_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_8_24_0' id='label_8_24_0'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_8_24_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_24' type='radio' value='No'  id='choice_8_24_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_8_24_1' id='label_8_24_1'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_8_23\"  class=\"gfield gfield--width-full gfield_contains_required field_sublabel_below field_description_above gfield_visibility_visible\"  data-js-reload=\"field_8_23\"><legend class='gfield_label'  >Does the person have capacity to give consent<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='gfield_description' id='gfield_description_8_23'>If the answer is no, we will make a decision on whether granting proxy access is in the patients best interest.<\/div><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_8_23'>\n\t\t\t<div class='gchoice gchoice_8_23_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_23' type='radio' value='Yes'  id='choice_8_23_0' onchange='gformToggleRadioOther( this )' aria-describedby=\"gfield_description_8_23\"   \/>\n\t\t\t\t\t<label for='choice_8_23_0' id='label_8_23_0'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_8_23_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_23' type='radio' value='No'  id='choice_8_23_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_8_23_1' id='label_8_23_1'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_8_22\"  class=\"gfield gfield--width-full field_sublabel_below field_description_above gfield_visibility_visible\"  data-js-reload=\"field_8_22\"><legend class='gfield_label gfield_label_before_complex'  >To be completed by Patient<\/legend><div class='gfield_description' id='gfield_description_8_22'><strong><p>I give permission to my GP practice to give the  proxy access to my online services to those named in Section 1.<\/p><\/strong>\n\n<ul>\n<li>&#8211; I reserve the right to reverse any decision I make in granting proxy access at any time.<\/li>\n<li>&#8211; I understand the risks of allowing someone else to have access to my health records.<\/li>\n<li>&#8211; I have read and understand the information leaflet provided by the practice.<\/li><\/ul>\n\n<strong><p>I consent to those named in Section 1 being given proxy access to the following services.<\/p><\/strong><\/div><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_8_22'><div class='gchoice gchoice_8_22_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_22.1' type='checkbox'  value='Online Appointments Booking'  id='choice_8_22_1'   aria-describedby=\"gfield_description_8_22\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_8_22_1' id='label_8_22_1'>Online Appointments Booking<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_8_22_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_22.2' type='checkbox'  value='Online Prescription Management'  id='choice_8_22_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_8_22_2' id='label_8_22_2'>Online Prescription Management<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_8_22_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_22.3' type='checkbox'  value='Full Medical Records'  id='choice_8_22_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_8_22_3' id='label_8_22_3'>Full Medical Records<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_8_27\"  class=\"gfield gfield--width-full gf_left_half gfield--width-half field_sublabel_below field_description_above gfield_visibility_visible\"  data-js-reload=\"field_8_27\"><label class='gfield_label' for='input_8_27' >Patient Signature<\/label><div class='ginput_container ginput_container_text'><input name='input_27' id='input_8_27' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_8_30\"  class=\"gfield gfield--width-full gf_right_half gfield--width-half field_sublabel_below field_description_above gfield_visibility_visible\"  data-js-reload=\"field_8_30\"><legend class='gfield_label gfield_label_before_complex'  >Date<\/legend><div id='input_8_30' class='ginput_container ginput_complex'>\n                                        <div class='gfield_date_day ginput_container ginput_container_date' id='input_8_30_2_container'>\n                                            <input type='number'  name='input_30[]' id='input_8_30_2' value='09'   aria-required='false'   placeholder='DD' min='1' max='31' step='1'\/>\n                                            <label for='input_8_30_2' class='screen-reader-text'>Day<\/label>\n                                        <\/div><div class='gfield_date_month ginput_container ginput_container_date' id='input_8_30_1_container'>\n                                        <input type='number'  name='input_30[]' id='input_8_30_1' value='04'   aria-required='false'   placeholder='MM' min='1' max='12' step='1'\/>\n                                        <label for='input_8_30_1' class='screen-reader-text'>Month<\/label>\n                                   <\/div><div class='gfield_date_year ginput_container ginput_container_date' id='input_8_30_3_container'>\n                                        <input type='number'  name='input_30[]' id='input_8_30_3' value='26262626'   aria-required='false'   placeholder='YYYY' min='1920' max='2027' step='1'\/>\n                                        <label for='input_8_30_3' class='screen-reader-text'>Year<\/label>\n                                   <\/div>\n                                <\/div><\/fieldset><\/div>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_8_44' class='gform_previous_button button' value='Previous'  onclick='jQuery(\"#gform_target_page_number_8\").val(\"3\");  jQuery(\"#gform_8\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_8\").val(\"3\");  jQuery(\"#gform_8\").trigger(\"submit\",[true]); } ' \/> <input type='button' id='gform_next_button_8_44' class='gform_next_button button' value='Next'  onclick='jQuery(\"#gform_target_page_number_8\").val(\"5\");  jQuery(\"#gform_8\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_8\").val(\"5\");  jQuery(\"#gform_8\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_8_5' class='gform_page' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_8_5' class='gform_fields top_label form_sublabel_below description_above'><div id=\"field_8_31\"  class=\"gfield gsection field_sublabel_below field_description_above gfield_visibility_visible\"  data-js-reload=\"field_8_31\"><h3 class=\"gsection_title\">Section 5: Identity Verification<\/h3><div class='gsection_description' id='gfield_description_8_31'><p>Verifying your identity online means we can process your request quicker.<\/p>\n\n<p>If you cannot provide identity verification online, you will need come to the practice with the relevant documents. <\/p>\n\n<p>We will contact you when we have processed your form.<\/p><\/div><\/div><div id=\"field_8_32\"  class=\"gfield gfield--width-full field_sublabel_below field_description_above gfield_visibility_visible\"  data-js-reload=\"field_8_32\"><label class='gfield_label' for='input_8_32' >Upload an ID document<\/label><div class='gfield_description' id='gfield_description_8_32'><strong><p>Upload a photo of your passport, driving license or other official ID document.<\/p><\/Strong>\n\n<p>Please make sure your photo is clear and relevant information can be read<\/p><\/div><div class='ginput_container ginput_container_fileupload'><input type='hidden' name='MAX_FILE_SIZE' value='2097152' \/><input name='input_32' id='input_8_32' type='file' class='large' aria-describedby=\"gfield_upload_rules_8_32 gfield_description_8_32\" onchange='javascript:gformValidateFileSize( this, 2097152 );'  \/><span class='gform_fileupload_rules' id='gfield_upload_rules_8_32'>Accepted file types: jpg, png, pdf, Max. file size: 2 MB.<\/span><div class='validation_message validation_message--hidden-on-empty' id='live_validation_message_8_32'><\/div><\/div><\/div><div id=\"field_8_34\"  class=\"gfield gfield--width-full field_sublabel_below field_description_above gfield_visibility_visible\"  data-js-reload=\"field_8_34\"><label class='gfield_label' for='input_8_34' >Upload a Photograph of yourself<\/label><div class='gfield_description' id='gfield_description_8_34'><strong><p>Take a photo of yourself using your phone or computer camera. In it you should be holding a piece of paper with today&#8217;s date written in dd-mm-yy format<\/p><\/Strong>\n\n<p>Please make sure your photo is clear and relevant information can be read<\/p><\/div><div class='ginput_container ginput_container_fileupload'><input type='hidden' name='MAX_FILE_SIZE' value='2097152' \/><input name='input_34' id='input_8_34' type='file' class='large' aria-describedby=\"gfield_upload_rules_8_34 gfield_description_8_34\" onchange='javascript:gformValidateFileSize( this, 2097152 );'  \/><span class='gform_fileupload_rules' id='gfield_upload_rules_8_34'>Accepted file types: jpg, png, pdf, Max. file size: 2 MB.<\/span><div class='validation_message validation_message--hidden-on-empty' id='live_validation_message_8_34'><\/div><\/div><\/div><fieldset id=\"field_8_37\"  class=\"gfield gfield--width-full gfield_contains_required field_sublabel_below field_description_above gfield_visibility_visible\"  data-js-reload=\"field_8_37\"><legend class='gfield_label gfield_label_before_complex'  >Confirmation<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_8_37'><div class='gchoice gchoice_8_37_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_37.1' type='checkbox'  value='I confirm the information I have entered is accurate.'  id='choice_8_37_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_8_37_1' id='label_8_37_1'>I confirm the information I have entered is accurate.<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_8_35\"  class=\"gfield gfield--width-full gf_left_half gfield--width-half gfield_contains_required field_sublabel_below field_description_above gfield_visibility_visible\"  data-js-reload=\"field_8_35\"><label class='gfield_label' for='input_8_35' >Your Signature<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_35' id='input_8_35' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_8_36\"  class=\"gfield gfield--width-full gf_right_half gfield--width-half gfield_contains_required field_sublabel_below field_description_above gfield_visibility_visible\"  data-js-reload=\"field_8_36\"><legend class='gfield_label gfield_label_before_complex'  >Date<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div id='input_8_36' class='ginput_container ginput_complex'>\n                                        <div class='gfield_date_day ginput_container ginput_container_date' id='input_8_36_2_container'>\n                                            <input type='number'  name='input_36[]' id='input_8_36_2' value='09'   aria-required='true'   placeholder='DD' min='1' max='31' step='1'\/>\n                                            <label for='input_8_36_2' class='screen-reader-text'>Day<\/label>\n                                        <\/div><div class='gfield_date_month ginput_container ginput_container_date' id='input_8_36_1_container'>\n                                        <input type='number'  name='input_36[]' id='input_8_36_1' value='04'   aria-required='true'   placeholder='MM' min='1' max='12' step='1'\/>\n                                        <label for='input_8_36_1' class='screen-reader-text'>Month<\/label>\n                                   <\/div><div class='gfield_date_year ginput_container ginput_container_date' id='input_8_36_3_container'>\n                                        <input type='number'  name='input_36[]' id='input_8_36_3' value='26'   aria-required='true'   placeholder='YYYY' min='1920' max='2027' step='1'\/>\n                                        <label for='input_8_36_3' class='screen-reader-text'>Year<\/label>\n                                   <\/div>\n                                <\/div><\/fieldset><div id=\"field_8_33\"  class=\"gfield gfield--width-full field_sublabel_below field_description_above hidden_label gfield_visibility_visible\"  data-js-reload=\"field_8_33\"><label class='gfield_label' for='input_8_33' >CAPTCHA<\/label><div id='input_8_33' class='ginput_container ginput_recaptcha' data-sitekey=''  data-theme='light' data-tabindex='0'  data-badge=''><\/div><\/div><div id=\"field_8_47\"  class=\"gfield gform_validation_container field_sublabel_below field_description_above gfield_visibility_visible\"  data-js-reload=\"field_8_47\"><label class='gfield_label' for='input_8_47' >Comments<\/label><div class='gfield_description' id='gfield_description_8_47'>This field is for validation purposes and should be left unchanged.<\/div><div class='ginput_container'><input name='input_47' id='input_8_47' type='text' value='' autocomplete='new-password'\/><\/div><\/div><\/div><\/div>\n        <div class='gform_page_footer top_label'><input type='submit' id='gform_previous_button_8' class='gform_previous_button button' value='Previous'  onclick='if(window[\"gf_submitting_8\"]){return false;}  if( !jQuery(\"#gform_8\")[0].checkValidity || jQuery(\"#gform_8\")[0].checkValidity()){window[\"gf_submitting_8\"]=true;}  ' onkeypress='if( event.keyCode == 13 ){ if(window[\"gf_submitting_8\"]){return false;} if( !jQuery(\"#gform_8\")[0].checkValidity || jQuery(\"#gform_8\")[0].checkValidity()){window[\"gf_submitting_8\"]=true;}  jQuery(\"#gform_8\").trigger(\"submit\",[true]); }' \/> <input type='submit' id='gform_submit_button_8' class='gform_button button' value='Submit'  onclick='if(window[\"gf_submitting_8\"]){return false;}  if( !jQuery(\"#gform_8\")[0].checkValidity || jQuery(\"#gform_8\")[0].checkValidity()){window[\"gf_submitting_8\"]=true;}  ' onkeypress='if( event.keyCode == 13 ){ if(window[\"gf_submitting_8\"]){return false;} if( !jQuery(\"#gform_8\")[0].checkValidity || jQuery(\"#gform_8\")[0].checkValidity()){window[\"gf_submitting_8\"]=true;}  jQuery(\"#gform_8\").trigger(\"submit\",[true]); }' \/> \n            <input type='hidden' class='gform_hidden' name='is_submit_8' value='1' \/>\n            <input type='hidden' class='gform_hidden' name='gform_submit' value='8' \/>\n            \n            <input type='hidden' class='gform_hidden' name='gform_unique_id' value='' \/>\n            <input type='hidden' class='gform_hidden' name='state_8' 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<\/div><\/div>\n                        <\/form>\n                        <\/div>","protected":false},"excerpt":{"rendered":"<p>Proxy Access: Use this form to request to the health records of someone you care for.<\/p>\n","protected":false},"author":1,"featured_media":3972,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"footnotes":""},"resourcetype":[547],"resourcecategory":[158,322,336,337,499],"class_list":["post-3971","resources","type-resources","status-publish","has-post-thumbnail","hentry","resourcetype-form","resourcecategory-how-to","resourcecategory-parenthood","resourcecategory-caring-for-others","resourcecategory-older-people","resourcecategory-childrens-health"],"acf":[],"publishpress_future_action":{"enabled":false,"date":"2026-04-16 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