Application for Online Proxy Access

To apply for proxy access to online services from the practice, please submit this form.

Application for Online Proxy Access

Section 1 - Patient Details

(This is the person whose records are being accessed)

Please use this format: DD/MM/YYYY
All responses we send will go to this email address.

Section 2 - Details of access required

Patient to complete if they have capacity

All patients 11 upwards, who are mentally competent, must complete and sign this section where possible. 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, this section may be signed by the patient’s named GP. Signature is not required for children under 11.

Please confirm the folllowing: *

I give permission to the Brunston & Lydbrook Practice to give the people listed in Section 3 proxy access to the online services as indicated below.

Please tick proxy access required:
*
I understand and agree with each statement: (please tick) *

Section 3 - The Proxy(s)

(These are the people seeking proxy access to the patient's online records)

Please use this format: DD/MM/YYYY
Please use this format: DD/MM/YYYY

I/we wish to have online access to the services ticked above in Section 2 for the patient named in Section 1.

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
Representative 2