Proxy Access Form

For Children Under the Age of 11

From the end of October 2023, the NHS is encouraging all patients to have full online access to their prospective medical record to support them with managing their health.  This access can be via a number of patient apps such as the NHS App or Patient Access. Some people will find online access to their detailed medical record helpful, but others may not feel comfortable with the details of every consultation being available online.

It is important to note that once you have requested that your medical information is available online we have no control over who sees it. It is entirely your responsibility to ensure that the company you use to access your information has appropriate safeguards in place to keep your information secure, and to take appropriate actions with password security and how you access your information to make sure that no unauthorised access happens.

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Cared for Patient’s Details
Online Services
Parent / Carer Details

(Requesting proxy access to online services for the patient named above) We need these details to be able to trace your existing online user account

(if registered at another practice)
Only following file extensions are allowed: jpg, jpeg, png, webp, pdf, doc, docx, pptx

Proxy access will be given to:

  • Book/cancel appointments
  • Request repeat medication
  • View the core medical record (medication & allergies)
  • View immunisations information

If you are registered with us, access will be added to your existing Online Services account – you will be able to switch to child/cared for person’s account via Linked Users (in drop-down menu under your name). If you are registered elsewhere, we will email you the registration document you need in order to link your account to our practice patient. Please hand this form to reception – if your request is not actioned within 1 week then please contact us

Privacy Consent

This form collects personal and medical information about you. We use this information to allow the practice team to contact you. Please read our Privacy Policy to discover how we protect and manage your submitted data.


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