Proxy Access Form

A proxy user is a user that is allowed to “connect on behalf of another user”.

You can only set up a proxy user if they have a registered account to use online services.

If you wish for another online user to have access to your records and be able to complete tasks on your behalf such as requesting prescriptions, booking appointments and accessing your medical records and information then you will need to set up this person as a ‘proxy user’.

  • 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.

Please carefully read the instructions before completing the proxy access form and visiting the practice in person with your proxy user

Proxy Access Form

Proxy Access Form

Patient Details

Please use date format DD/MM/YYYY
All correspondence will go to this email address.

Section 1 - Responsibility

Please tick that you agree:

Section 2 - Granting Proxy Access

  • I reserve the right to reverse any decision I make granting proxy access at any time.
  • I understand the risks of alloiwng someone else to have access to my health records.
  • I have read and understand the information leaflet provided by the practice.
This is the name of the person you wish to give access.
This is the name of the person you wish to give access.

Section 3 - Proxy Access Level

Please grant the following access to my proxy/ies:

Section 4 - Only for patients without capacity

  • I  reserve the right to reverse any decision I make granting proxy access at any time.
  • I understand the risks of alloiwng someone else to have access to my health records.
  • I have read and understand the information leaflet provided by the practice.
This is the name of the person you wish to give access.
This is the name of the person you wish to give access.
*
Under 16's - If there is no ID available a parent/carer can bring their ID in to vouch on your behalf.

Next Steps

The person you are granting proxy user status to must download, print and fill out Section 5 and 5.1 after you have filled out the appropriate sections above, and bring it with you to the practice.