Consent to proxy access to GP Online Services

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

I give permission to my GP practice to give the following people proxy access to the online services as indicated below in section 2.

The representatives

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

Person 1

Person 2

Section 3

I/we (the above named representatives) wish to have online access to the services ticked in the box above in section 2 for the above named patient.

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

(This is the person whose records are being accessed)

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