Consent to proxy access

(This is the person whose records are being accessed)

Surname:

Forename:

Date of Birth:

For example, 31/03/1980

What is your sex?

Male

Female

Other

As recorded on your medical record

Address including postcode:

Phone number:

Email address:

All responses we send will go to this email address. Please use representative email address if the patient does not have capacity.

Surname:

Forename:

Address including postcode:

Date of Birth:

Relationship to patient:

Phone number:

Email address:

Is this access going to be limited in anyway?

Yes

No

Please specify the limitations:

e.g. ‘Only for test results’, ‘For arranging and cancelling appointments’, ‘For a pre-defined time period’, etc.

In order to complete this form, you will need to upload or hand in proof of ID to reception:

Maximum upload size: 67.11MB

This can be ID such as a current signed passport, original birth certificate or current UK or EEA photocard driving licence.

Confirmation

I confirm that I give permission for the Practice to communicate with the person identified above in regards to my medical records.

Patient signature:

Date:

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