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East Harling & Kenninghall Medical Practice NHS GP Surgeries in Norwich

Proxy access request

Patient details

Details of the patient for whom the request relates.

Title: *

Mr

Mrs

Miss

Ms

Mx

Other

Please specify: *

First name(s): *

Surname: *

NHS number: *

Get help to find your NHS number online

Date of Birth: *

Please use this date format: DD/MM/YYYY.

Phone Number: *

Email Address:

Address, including postcode: *

Patient representative (proxy) details

Title: *

Mr

Mrs

Miss

Ms

Mx

Other

Please specify: *

First name(s): *

Surname: *

Date of Birth: *

Please use this date format: DD/MM/YYYY.

Phone Number: *

Email Address: *

Any responses we send will go to this email address

Address, including postcode: *

Relationship to Patient: *

Legal basis for proxy access: *

Parental responsibility for a patient under 16 years

Lasting power of attorney

Carer or guardian

Other

Which online services do you wish to grant access to?

The representative stated on this form, is allowed proxy access to the following services: *

Booking appointments

Requesting repeat prescriptions

Accessing medical records (once available)

Please select all that apply.

Parental proxy access for children

If you are requesting proxy access for a child, the practice must verify identity and parental responsibility. You will need to provide photo ID for yourself and the child (for example, passports). You must also provide evidence of parental responsibility, such as a birth certificate. If the child is aged 11 years or over, the child must also give their consent before proxy access can be granted.

Confirmation *

I confirm that I have parental responsibility for the child named on this form and can provide supporting documentation, i.e. a birth certificate.

Child consent *

I understand that if the child is aged 11 years or over, the practice will require the child’s consent before proxy access can be granted.

Consent

Patient’s consent *

I understand that this consent will remain in force indefinitely. However, my doctor may, at my request, override this authority to allow access to my medical records via the Patient Access/Online Services at any time. 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 medical records.

Representative (proxy) consent *

I will treat any information provided confidentially. I will not disclose information to a third party without agreement. I will only use the information in the person that I have proxy access for in their best interest.

Signature

Please enter your full name: *

Date:

Confirmation *

I understand this form is not for urgent medical help

Proof of identity

Representative (proxy) identity

Maximum upload size: 67.11MB

To register for proxy access, we need to verify your identity. Please provide the practice with 1 photo ID such as passport or drivers licence and 1 form of ID with your home address on such as a recent utility bill or bank statement.

If proxy access is being requested for a child, the practice will also require proof of the child’s identity (for example, a passport) and documentation confirming parental responsibility, such as a birth certificate.

Confirmation *

I understand – I will need to attend the practice and provide originals of the required ID documents requested to complete my online registration for proxy access.

If you are human, leave this field blank.

East Harling Surgery
Market Street
East Harling
Norwich
NR16 2AD

Get directions

01953 717204

Kenninghall Surgery
Quidenham Road
Kenninghall
Norwich
NR16 2EF

Get directions

01953 887208

Register with the surgery

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