Application for Proxy Access Form

Application for Proxy Access Form

Before you apply for proxy access to medical records, there are some other things to consider.

Although the chances of any of these things happening are very small, you are asked that you have read and understood the following before you are given login details.

Things to consider

Forgotten history
  • There may be something you have forgotten about in your record that you might find upsetting
    • Abnormal results or bad news
  • If your GP has given you access to test results or letters, you may see something that you find upsetting. This may occur before you have spoken to your doctor or while the surgery is closed, and you cannot contact them.
    • Choosing to share your information with someone
  • It’s up to you whether or not you share your information with others – perhaps family members or carers. It’s your choice, but also your responsibility to keep the information safe and secure.
    • Coercion
  • If you think you may be pressured into revealing details from your patient record to someone else against your will, it is best that you do not register for access at this time.
    • Misunderstood information
  • Your medical record is designed to be used by clinical professionals to ensure that you receive the best possible care. Some of the information within your medical record may be highly technical, written by specialists and not easily understood. If you require further clarification, please contact the surgery for a clearer explanation.
    • Information about someone else
  • If you spot something in the record that is not about you or notice any other errors, please log out of the system immediately and contact the practice as soon as possible.

    • Section 1 – Patient Details

    (This is the person whose records are being accessed)
    Name
    Date of Birth
    Gender
    Address
    All patients aged 13 and over must sign to confirm their consent. If a patient is medically unable to consent, please leave this section blank.
    MM slash DD slash YYYY

    Section 2 – Details of access required

    Please tick proxy access required

    Section 3 – Details of the representative(s) seeking proxy access

    (These are the people seeking proxy access to the patient’s online records, appointments or repeat prescription)
    Name
    MM slash DD slash YYYY
    Address
    Drop files here or
    Max. file size: 1 GB.
      Please upload proof of your ID and/or proof of address. Photos of patients are not accepted as ID.
      Max. file size: 1 GB.
      For patients under 13
      Date