Online Access Proxy Form

Complete this form to request a representative be given access to the online medical services as indicated. Please note both parties will need to be contacted by the practice prior to access being granted and your representative may need to provide identification as required by the practice.

Last Updated: 29/06/2021

Patient details

Full Name *

DOB *

Representative details

Full Name *

Relationship to patient *

DOB *

Address *

Telephone No. *

Access required

I agree that the above named representative can be given access to the following:

When is best to contact you and your representative?

As both parties will need to be contacted via telephone prior to access being granted please can you let us know the best time of day to contact both you and your representative (can be at different times for each of you)

Please provide details below:

Declaration

In submitting this form both my representative and I agree to observe the practice policy with regard to use of online services and immediately report to the practice any concerns in either the content seen or activity around the online information. Proxy access for children will automatically be terminated on their 14th birthday. Further applications can be made to cover from age 14 to age 16. Both my representative and I acknowledge that we will both be contacted by the practice to confirm our identity prior to access being granted. If the representative is not a patient at the practice they will also have to provide the practice with a copy of their ID. A member of the practice will will be in touch with further information following submission of this form.

Please confirm whether you agree / disagree with the above declaration. *

Agree

Disagree

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