Proxy request for online services

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.

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.

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.