Consent to Proxy Access to GP Online Services (Child 11-15)

Section 1 – Patient Details

(This is the person whose records are being accessed)

All responses we send will go to this email address.
Please select the access required:

Section 2 – Terms and Conditions

I have read and understood and accept the following terms and conditions:

Section 2 – Details of access required

Please confirm the folllowing:
I give consent for the parent/guardian/carer named below in section 3 to use online access on my behalf to:

Section 3 – 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:


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