Register for Online Access - Proxy User

Use this form to apply for proxy access to another persons account. This could be an elderly relative or a child for example. Once the form is received a consent form will be sent to be signed by anyone over 11 years old. The proxy account will be linked to your own account meaning you will only need to use one log in.

Last Updated: 17/10/2023

Patient Details

Please complete this section with the details of the account you would like to access. Once this form is received we will send a consent form to be signed by any patient over 11 years old.

Name *

Address *

Post Code *

Date of Birth *

Relationship to patient. *

What services would you like access to?

Review and order repeat medications? *

Yes No

View medical record? *

Yes No

Change personal details? *

Yes No

Record sharing? *

Yes No

User Details

Please complete this section with your own details.

Name *

Address *

Post Code *

Date of Birth

Do you already have your own online access account? (If no please complete Access to Own Record Form) *

Yes No

Email Address *

Mobile Number *

I give consent to be contacted by: (please select all that apply) *

Text

Declaration

I have read and understood the information leaflet provided. *

Yes

I will be responsible for the security of the information that I see or download. *

Yes

If I choose to share my information with anyone else, this is at my own risk. *

Yes

I will contact the practice as soon as possible if I suspect that my account has been accessed by someone without my agreement. *

Yes

If I see information on my record that is not about me, or is inaccurate, I will contact the practice as soon as possible. *

Yes

I understand that the practice has the right to refuse access to my online record should access not be considered in my best interests. *

Yes

I understand the practice has the right to remove access to services from anyone who does not use them responsibly. *

Yes

I consent to the practice collecting and storing my data from this form. *

Yes

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Register for Online Access - Proxy User

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