Proxy Access Form

A Proxy Access user is a user that is allowed to contact the surgery online on behalf of a patient using Patient Access.

You can only be set up with a proxy user account if you have an existing online access account.

If you wish for another user to have access to your records and be able to complete tasks on your behalf such as ordering prescriptions, booking appointments and accessing medical information you must have a proxy user account set up.

  • If you have a child under the age of 12 you can request proxy access to your child’s medical records. When your child reaches 12 years old the proxy access will be reduced to only allow you to make appointments on their behalf and repeat prescription requests. Your child will then need to give consent for any further information to be shared. At the age of 16 proxy access will cease unless your child does not have capacity* to manage their own healthcare.
  • If the patient does not have capacity to confirm proxy access then the access will be forwarded for approval by the GP.
  • For people aged 16 years and older they can request direct online access to their medical records themselves and will have responsibility for protecting their own registration details and password.
  • Proxy application will not be accepted from third party organisations such as insurance company or solicitors.
Proxy Access Form

Section

Please tick that you agree:
I, the patient, give permission to my GP practice to give the representatives stated on this form, proxy access to the online services as indicated below in section 2.

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 record.

I have read and understood the information leaflet provided by the practice.

Granting Access

I reserve the right to reverse any decision I make 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.

Is the above named person considered your next of kin?
Is the above named person considered your formal carer?

Access Levels

Please grant the following access to my proxy:
I understand that signed consent must be provided to the surgery before proxy access can be granted.

I will download the Proxy Access Consent Form and return it to the surgery within 5 working days.

I understand that if the consent is not received the surgery will not grant access for my request.