Register for online services on behalf of someone else (Proxy Access)

Note: 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.

For verification purposes, to complete your registration you will need to attach two forms of identification to the form below. One form of photo ID (passport, driving licence) and one from of proof of address (utility bill, bank statement).

Online access Patient Information

Before you apply for online access to your record, there are some other things to consider.

Although the chances of any of these things happening are very small, you must read and understand the following before you are given login details. Things to consider:

Forgotten History

There may be something you have forgotten about in your record that you might find upsetting.

Abnormal results or bad news

If your GP has given you access to test results or letters, you may see something that you find upsetting to you. This may occur before you have spoken to your doctor or while the surgery is closed and you cannot contact them.

Choosing to share your information with someone

It’s up to you whether or not you share your information with others – perhaps family members or carers. It’s your choice, but also your responsibility to keep the information safe and secure.

Coercion

If you think you may be pressured into revealing details from your patient record to someone else against your will, it is best that you do not register for access at this time.

Misunderstood Information

Your medical record is designed to be used by clinical professionals to ensure that you receive the best possible care. Some of the information within your medical record may be highly technical, written by specialists and not easily understood.

Information about someone else

If you spot something in the record that is not about you or notice any other errors, please log out of the system immediately and contact the practice as soon as possible.

Proxy access to GP online services

Section 1 (to be completed by the patient)

I give permission to my GP practice to give proxy access to the online services (as indicated below in Section 2) to the individuals named below *
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 online access patient information above provided by the practice. *
This is automatically completed.

Section 2 (to be completed by the patient)

I wish to have access to:
Please be aware that some of the above services may not be available.

Section 3 (to be completed by the representatives)

I/we wish to have online access to the services ticked in the box above in Section 2 for the patient in Section 4. *
I/We understand my/our responsibility for safeguarding sensitive medical information and I/we understand and agree with each of the following statements:
I/we have read and understood the online access patient information above 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 *
I/we will contact the practice as soon as possible if I/we suspect that the account has been accessed by someone without my/our agreement *
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 *
This is automatically completed.

Section 4 The Patient – (This is the person whose records are being accessed)

Please use format day/month/year e.g. 12/05/1979

The Representatives – (These are the people seeking proxy access to the patient’s online records, appointments or repeat prescription).

Please use format day/month/year e.g. 12/05/1979
Relationship to patient

Verify your identity

For verification purposes, to complete your registration you will need to attach two forms of identification to the form below. One form of photo ID (passport, driving licence) and one from of proof of address (utility bill, bank statement).
Maximum upload size: 10MB
We accept the following files: jpg, jpeg,jpe, gif, tiff, pdf, doc,and docx

Privacy Policy

This form collects your name, date of birth, email, other personal information and medical details. This is to confirm you are registered with the practice, to allow the practice team to contact you and also to update your medical records held by the practice and our partners in the NHS. Please read our Privacy Policy to discover how we protect and manage your submitted data.