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Proxy access to online services

Proxy access to online services

Form summary

Which online services would you like proxy access to? *
Select all options that are relevant to you
Does the patient have the capacity to consent to proxy access?
Proxy access may be considered by the surgery to be in the patient’s best interest
Does the patient have any of the following contact details?
Select all options that are relevant
The email address given at the start of the form will be used to reply to this request

Patient declaration

Before you continue, the patient needs to read and agree to the following statements:

  • I give permission to my GP surgery to give my representative 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 understood the information and things to consider about proxy access

Enter the patient’s signature to confirm:

Representative declaration

Before you continue, you need to read and agree to the following statements:

  • I have read and understood the information and things to consider about using online services
  • I will be responsible for the security of the information that I see or download
  • If I choose to share my information with anyone else, this is at my own risk
  • If I suspect that my account has been accessed by someone without my agreement, I will contact the surgery as soon as possible
  • If I see information in my record that is not about me or is inaccurate, I will contact the surgery as soon as possible
  • If I think that I may come under pressure to give access to someone else unwillingly, I will contact the surgery as soon as possible

Enter your signature to confirm:

Upload photographic ID and proof of address to complete your registration
Maximum upload size: 5.24MB
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