Consent to Proxy Access to GP Online Services

Last Updated: 22/12/2023

  • Consent to Proxy Access

    If the patient does not have capacity to consent to grant proxy access and proxy access is considered by the practice GP to be in the patient's best interest, this section may be omitted.

    I confirm that I give permission to my GP practice for the above name persons to have proxy access to online services. 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. (optional)
    Today's Date (optional)
    For example, 15 3 1984

  • The Patient

    This is the person whose records are being accessed

    Date of Birth
    For example, 15 3 1984

  • Representatives

    Please give details of the representative(s) wishing to have online access to the services requested in the Permission Section.

    I/We understand my/our responsibility for safeguarding sensitive medical information.
    I/we have read and understood the information leaflet provided by the practice and agree that i/we will treat the patient information as confidential.
    I/we will be responsible for the security of the information that I/we see or download.
    If I/we see information in the record that is not about the patient or is inaccurate I/we will contact the practice as soon as possible. I/we will treat any information which is not about the patient as being strictly confidential.

  • Permission

    I give permission for my representatives named in this form to be given access to the following:

  • The Representatives

    These are the people seeking access to the patient's online records, appointments or repeat prescriptions.

    Date of Birth
    For example, 15 3 1984
    Date of Birth (optional)
    For example, 15 3 1984

  • Electronic Submission

    This form cannot be processed without identification being provided for each person named above.

    Please confirm you have sent copies of each person's identification to: medical.reports@nhs.net - your application will not be processed without identification.
This form is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.