Consent to Proxy Access to GP Online Services (Child 10 and under)

Section 1 – Patient Details

(This is the person whose records are being accessed)

All responses we send will go to this email address.

Section 2 – Details of the representative seeking proxy access

(This is the parent/guardian/carer seeking proxy access to the patient’s online records, appointments and repeat prescription)

I wish to have online access on behalf of the child named above in Section 1.

I understand my responsibility for safeguarding sensitive medical information and I understand and agree with each of the following statements:

Representative

Proof of Identification

Maximum file size: 67.11MB