Proxy Online Access for Adults

Patient’s Full Name
Patient’s Date of Birth
Patient’s Address

Information regarding access to online services

You have decided to grant someone else access to you medical record online. The person you are granting access to will be able to do the following things on your medical record:

1. Book and cancel appointments

2. Order medication on your behalf

3. See your allergies and recent medication

4. See coded details of your consultation with any doctor or nurse at the surgery (optional)

Details of the person you want to give access to

Full Name
Date of Birth

Stopping access

Even if you grant access today, you can STOP the access at any time by letting us know that you no longer want this person to have access to your record. You can also set a specific date you want the access to stop by filling in the section below.

Date you want the access to stop
If you leave this blank it will automatically be set to stop in one year’s time.

Please sign below to confirm that you have read and understood the information on this form.