Proxy Access for GP Online Services – Children aged 0-10 years

To register for our online services you will need to complete this form and then visit the practice, bringing  with you two forms of identification. One of these items should include your photograph.

We will then issue you a username and password.

Once you are registered you will be able to use the service to:

• Order your repeat prescriptions
• Make an appointment
• Cancel an appointment
• Change your contact details
• Review your medications and known allergies

After submitting this form, please ensure you visit any one of our three surgery reception desks to show us your Photographic ID. Please note, without seeing your ID we are unable to process this request.

Child Details

Name

First Last

Date of birth

Day

Month

Year

Contact number

Address

Street Address Address Line 2 City Postcode

Proxy User

I wish to have access to the following services on behalf of the above named child and I have parental responsibility.

Please select one of the below:

I am the birth mother

I am the birth father and married to the mother at the time of child’s birth or subsequently

I am the birth father and not married to the mother, but the child was born after 01/12/2003 and my name is on the birth certificate

I am an adoptive parent

I am the child’s legal guardian

I have court-appointed parental responsibility

Other

Pease specify

I wish to have access to the following online services for the above patient (please select all that apply):

Booking my appointments

Requesting my repeat prescriptions

Updating my contact details (demographics)

Secure online access to my full electronic GP record

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

– If I choose to share information with anyone else, this is at my own risk

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

– If I see information in the record that is not about the patient or inaccurate, I will contact the practice as soon as possible

Your Details

Name

First Last

Date of birth

Day

Month

Year

Contact number

Email

Enter Email Confirm Email

Are you already registered for GP online services at the practice?

Yes

No

Address

Street Address Address Line 2 City Postcode

Relationship to patient:

Signature

Reset to re-sign.

Date

Day

Month

Year