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Proxy access to GP online services (adult)

Proxy Access to GP Online Services (Adult)
Required fields are labelled
Does the patient have the capacity to grant proxy access? Required

Online Services to be Accessed

I wish my representative/s 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.

Application for online access to patient’s medical record

I/we, the representative/s, wish to have online access to the services chosen above for the named patient. I/we understand the responsibility for safeguarding sensitive medical information and I/we understand and agree with each of the following statements.

I/we wish to have access to the patient’s medical record and have read and understand the following: Required
Enter full name
Enter full name

Patient Details

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

Representative 1

These are the people seeking proxy access to the patient’s online records, appointments or prescriptions
Any responses from the practice will go to this email address

Representative 2

File Upload

Do not upload sensitive photographs of genitalia, bottoms (anus), breasts or minors without asking a healthcare professional first. Your uploads may be stored on your health record.

Phoenix Cirencester
9 Chesterton Lane
Cirencester
GL7 1XG

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01285 652056

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Phoenix Cirencester
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26 April 2017
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