Online services proxy access request form

  • Patient details

    Details of the patient for whom the request relates. Please note you will need the patients NHS number (get help to find your NHS number online)

    Date of birth
    For example, 15 3 1984

  • Representative (proxy) person details

    Please provide the following information about the representative (proxy) to be granted proxy access.

    Date of birth
    For example, 15 3 1984

  • Legal basis for request

    Please provide the basis for this request.

    Legal basis for proxy access

  • Which online services do you wish to grant access to?

    The representative stated on this form, is allowed proxy access to the following services:

    I wish to grant / have access to the following online services (please tick all that apply)

  • Patient's consent

    Patient's consent

  • Representative (proxy) consent

    Representative (proxy) consent(

  • Signature of patient or representative (proxy)

    Today's date
    For example, 15 3 1984
    Not for urgent medical help
    Representative (proxy) identity - To register for Online Services Proxy Access we need to verify the representative's identity. Please provide the practice: One photo ID such as passport or drivers licence and one form of ID with your home address on such as a recent utility bill or bank statement.
    Consent - By submitting your details you are consenting to providing this information for improving our services to you. The data you supply on this form will be securely stored on our website, which is hosted by a third party. We will retain this information on the website for no longer than 7 calendar days. Your contact details will not be sold or shared with a third party. I understand I can revoke this consent at anytime by contacting the practice. Our privacy policy can be viewed on this website.
The information you provide on this form will be sent to our practice and used only to deal with your request. Depending on the form, this may include your contact details, personal information and health information. The practice may add it to your medical record and, where needed for your care, share it with other NHS and care services. To find out how we protect and use your information, please read our privacy policy on our website.
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Page last reviewed: 19 September 2024
Page created: 15 October 2026