Online services proxy access request form

Fill in the form below to request proxy access for online services.

Section 1: Patient details

Details of the patient for whom the request relates
Title(Required)

Date of birth(Required)
Email address

Section 2: Representative (proxy) person details

Please provide the following information about the proxy.
Title(Required)

Date of birth(Required)
Email(Required)

Section 3: Legal basis for request

Please provide the basis for this request.
Legal basis for proxy access(Required)

Section 4: 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(Required)
Please tick all that apply

Section 5: Patient's consent

Patient's consent(Required)

Section 6: Representative (proxy) consent

Representative (proxy) consent(Required)

Signature of patient or representative (proxy)

Today's date(Required)
Not for urgent medical help(Required)
Representative (proxy) identity(Required)
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(Required)

Date published: 28th November, 2024
Date last updated: 28th November, 2024