Proxy Online Access Application Form: Covid-19 Adaptation

All questions marked with an asterisk * are required.

Proxy Online Access Application

Patient Details

Enter Email
Confirm Email
Please use format day/month/year e.g. 12/05/1979
How can we contact the patient? *
Please select all methods we can use if we need to get in touch with you.

Patient Consent

By completing this form I (the above patient) understand that I am giving permission to the representative named below to have proxy access to my online medical record for the purposes listed below:
It may still be possible to set up proxy access if it is deemed to be in the patient’s best interest but will require a review by the patient’s GP.

Access Requirements

I wish to grant access to the representative named below for the following online services *
Selected online services *

Please note that the full text of your GP medical record is not currently available to view.

Items marked with an asterisk will be available from the date of registration with The Practice.

Please note that we are making it easier for patients to grant proxy access to relatives and carers during the Coronavirus pandemic. Due to the increased risks of confidentiality and coercion with proxy access we will only be making the following services available at this stage:

  • Book appointments
  • Order repeat medication
  • View test results

We will keep a record of any additional requests for access and process these once normal procedures have been resumed.

Representative Details

Enter Email
Confirm Email
Please use format day/month/year e.g. 12/05/1979
How can we contact you as the representative? *
Please select all methods we can use if we need to get in touch with you.

Patient and Representative Responsibilities

Please confirm you understand your responsibilities when using online services.

Identity Check

Normally patients would be required to bring Photo ID to the practice in order to confirm identity
but during the Covid-19 pandemic we will be verifying identity from your records.

Please can you answer as many of the following questions as you are able to help us verify the patient’s identity:

Additional Information

Due to the increased risks of confidentiality and coercion when authorising proxy access we may need to contact both the patient and the representatives to ask further questions before we set up a proxy account. Thank you for your understanding and cooperation.

Privacy Policy

This form collects your name, date of birth, email, other personal information and medical details. This is to confirm you are registered with the practice, to allow the practice team to contact you and also to update your medical records held by the practice and our partners in the NHS. Please read our Privacy Policy to discover how we protect and manage your submitted data.