Access to Medical Record – Third Party (Proxy)

If you would like to nominate a family member, carer or someone else to have access to liaise with the surgery on your behalf or to have access to your medical record, you will need to complete the “Application for Third-Party Access to Healthcare Information” form.

For further information, please review our information leaflet.

To download the form, click here.

The form will need to be signed and returned to the reception desk.

If you want to send the form back electronically, please send it to [email protected] for the attention of Deepa Kapila. Someone from the practice will call you on the telephone to confirm it was you who completed and returned the form.