Proxy Access to GP Online Services (Under 16)

Application for online access to child’s medical record

I, the parent/guardian, request access to the patient’s medical record.

I have read and understand the following: *

Online Services to be Accessed

I, the parent/guardian, wish to have access to the following online services (Please select all that apply):

*Please allow two working days for your electronic access to be activated.

Please note you will need to verify your identity with two forms of identification, one must contain a photo and one must contain address details. Acceptable documents include passports, photo driving licenses and bank statements, utility bills (not mobile telephone bills).

If you need any further information or assistance with this matter, please ask at reception.

Parent/Guardian signature

I understand my responsibility for safeguarding sensitive medical information and I understand and agree with
each of the following statements:

Confirmation:
Enter full name

Patient Details

This is the person whose records are being accessed
Please use format DD/MM/YYYY.

Representative (the parent/guardian)

This is the person seeking proxy access to the patient’s online records, appointments or prescriptions.
Any responses from the practice will go to this email address
File Upload
Maximum upload size: 67.11MB