Accessing someone else’s information

As a parent, family member or carer, you may be able to access services for someone else. We call this having proxy access.

To requests proxy access:

Once proxy access is set up, you can access the other person’s profile in your NHS account, using the NHS App or website.

Proxy Access Patient Consent Form

(The person whose records another individual(s) is to be given access to)

Name

First Last

Date of Birth

Gender

Male

Female

Address

Street Address Address Line 2 City Postcode

Phone Number

Name

First Last

Address

Street Address Address Line 2 City Postcode

Relationship to Patient

Is this access going to be limited in anyway?

Yes

Proof of ID and Address

Max. file size: 1 GB.

Please upload proof of your ID and proof of address

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

Your Signature

Date