To complete this form the patient allowing proxy access to their record will need to present in person to the surgery with proof of ID (Photo ID or proof of residence)
Last Updated: 22/09/2020
Section 1
The representatives
Person 1
Person 2
Section 3
Section 2
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 information leaflet provided by the practice.
The patient