Proxy Access Application Form B

 
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Application for Online Access

Proxy Access Application Form B

To give consent for proxy access to their online services.

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Cared for Patient’s Details
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Consent

To be completed by the person named above unless lacks capacity because of medical condition

I give consent for the person named below to have online services access to: 

Book/cancel appointments for me: *
Request my repeat medication: *
View my core medical record (medication & allergies): *
View the immunisations information in my care record: *
View test results in my care record: *
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Please provide copy of legal paperwork (Power of Attorney/Court Appointed Deputy). If paperwork cannot be supplied then GP will need to confirm incapacity before access is given.

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Parent / Carer Details

(Requesting proxy access to online services for the patient named above) We need these details to be able to trace your existing online user account

Title: *
Gender: *
Registered At: *
(if registered at another practice)
Relationship to child above: *

Important

If you are registered with us, access will be added to your existing Online Services account – you will be able to switch to child/cared for person’s account via Linked Users (in drop-down menu under your name).

If you are registered elsewhere, we will email you the registration document you need in order to link your account to our practice patient. Please hand this form to reception – if your request is not actioned within 1 week then please contact us

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Privacy Consent

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Providing NHS Services

Contact

Wellspring GP Surgery
Beam Street
Redfield
Bristol
BS5 9QY

Telephone: 0117 9557711

The Practice

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