Proxy Access Form 

For patients aged 11 and over

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Cared for Patient’s Details

To give consent for proxy access to their online services

Access required
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)

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


A GP will need to confirm capacity / incapacity before access is given. 

  • This will require a routine appointment with the GP first to complete the assessment.
  • Please contact the surgery to make this appointment.
  • We will add your application to the record in the meantime. 

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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