Proxy Online Access for Adults Patient’s Full Name First Last Patient’s Date of Birth Day Month Year Patient’s Address Street Address Address Line 2 City Postcode Information regarding access to online servicesYou have decided to grant someone else access to you medical record online. The person you are granting access to will be able to do the following things on your medical record: 1. Book and cancel appointments 2. Order medication on your behalf 3. See your allergies and recent medication 4. See coded details of your consultation with any doctor or nurse at the surgery (optional) Details of the person you want to give access toFull Name First Last Date of Birth Day Month Year Address Street Address Address Line 2 City Postcode Stopping accessEven if you grant access today, you can STOP the access at any time by letting us know that you no longer want this person to have access to your record. You can also set a specific date you want the access to stop by filling in the section below. Date you want the access to stop Day Optional Month Optional Year Optional If you leave this blank it will automatically be set to stop in one year’s time.Please sign below to confirm that you have read and understood the information on this form.Signature