Consent to proxy access to GP online services

If you would like to request proxy access to GP online services, please use this form.

If the patient does not have capacity to consent to grant proxy access and proxy access is considered by the practice to be in the patient’s best interest section 1 of this form may be omitted.

Consent to proxy access to GP online services

Consent to proxy access to GP online services

This is for the person whose records are being accessed.

Section 1:

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.

Section 2:

The representatives stated on this form, are allowed proxy access to the following services:

Section 3:

I/We, the represntatives, wish to have online access to the services ticked in the box above in section 2 for the patient of this form.

I/We understand my/our responsibility for safeguarding sensitive medical information and I/We understand and agree with each of the following statements:

Representative 1:

This is for the people seeking proxy access to the patient's online records, appointments or repeat prescription.

Representative 2:

This is for the people seeking proxy access to the patient's online records, appointments or repeat prescription.