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Please complete this form if you are registered patient between the ages of 13-16 at one of our practices and would like to give proxy access for someone to access your medical records on your behalf, such as your parent, guardian or carer. If you do not have capacity to complete this form, please contact your GP practice to discuss this further with your representative.

Please ensure you have read the patient information leaflet to understand potential outcomes of full record access. Please note that Full Record Access is enabled following a review of your notes. We may need to restrict some information, if we do we will contact to discuss.

I wish to have access to the following online services (please tick all that apply):

Thanks for submitting the form.


Someone from our GP Practice will get in touch with you shortly. 

Between their 13th and 16th birthday:

  • a young person may be given access to their records if their clinical team assesses their ability to understand the information is sufficient


  • a young person may choose to share their online access with their parent/carer/guardian


  • Parents may continue to have full access where this is in the best interests of the young person.

The Patient

The Representative (This is the person seeking proxy access to the patient’s online records, appointments or repeat prescription.)

Terms and Conditions:

  • I reserve the right to reverse any decision I make in granting proxy access at any time


  • I understand the risks of allowing someone else to have access to my health records.


  • I have read and understand the information leaflet provided by the practice

Terms and Conditions:

  • I have read and understood the information leaflet provided by the practice and agree that I will treat the patient information as confidential​


  • I will be responsible for the security of the information that I see or download


  • I will contact the practice as soon as possible if I suspect that the account has been accessed by someone without my/our agreement


  • If I see information in the record that is not about the patient, or is inaccurate, I will contact the practice as soon as possible. I will treat any information which is not about the patient as being strictly confidential


  • I consent to be contacted by the practice via text messaging service where appropriate

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