Proxy Access Form

Proxy access was developed to allow someone other than the patient to access and manage parts of their GP online services account. The proxy is given their own online access account. It is often used by the parents or recognised carers of young children, and recognised carers of adults. Please be advised we will contact you asking for a copy of valid photo ID.

Last Updated: 17/10/2023

Proxy Access Form

Have you read section 1 and 2? *

Yes No

Are you filling out this form for yourself? *

Yes No

If no, please state who is filling out this form for you.

Your details - Please include your full name, date of birth and NHS number (if known) *

The representative details ( this is the person seeking proxy to the patient’s appointment and repeat prescriptions) full name, date of birth, address, telephone number and email address. *

Please state your relationship to the person you are seeking online access for. *

Are you a carer for this person?

Yes

Other

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Proxy Access Form

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