Request Proxy Access to GP online services

Note: If the patient does not have capacity to consent to grant proxy access and proxy access is considered by the practice to be in the patient's best interest, section 1 of this form may be omitted.

If you are making a proxy access aplication to access the medical records of a child, we will need to see evidence of parental responsiblity. 

Last Updated: 19/12/2024

Section 1

I ( named in below) give permission to my GP practice to give the following people.... proxy access to the online services as indicated below in 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 informtion leaflet provided by the practice. 



Section 2


Section 3

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

for.... (name of patient)

I/we understand my/our responsiblity for safeguarding sensitive medical information and I/we understand and agree with each of the following statements:








The Patient

This is the person whose records are being accessed











This form is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.