Proxy Access Application Form B

For cared for patients aged 11 years and over

 

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Please complete our online form

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Cared for Patient’s Details

To give consent for proxy access to their online services

Consent

To be completed by the person named above unless lacks capacity because of medical condition

I give consent for the person named below to have online services access to: 

Please provide copy of legal paperwork (Power of Attorney/Court Appointed Deputy). If paperwork cannot be supplied then GP will need to confirm incapacity before access is given. 

Parent / Carer Details

(Requesting proxy access to online services for the patient named above) We need these details to be able to trace your existing online user account

(if registered at another practice)

If you are registered with us, access will be added to your existing Online Services account – you will be able to switch to child/cared for person’s account via Linked Users (in drop-down menu under your name). If you are registered elsewhere, we will email you the registration document you need in order to link your account to our practice patient. Please hand this form to reception – if your request is not actioned within 1 week then please contact us

Privacy Consent

This form collects personal and medical information about you. We use this information to allow the practice team to contact you. Please read our Privacy Policy to discover how we protect and manage your submitted data.

 
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