Request Proxy Access Form




Please complete our online form

Your submission will not get looked at until the next working day of the surgery.

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Cared for Patient’s Details

This form is specifically for children living at a different address to the parent/carer requesting access, or where the parent/carer is not a registered patient at this surgery, or when we have asked you to complete the form.

If you use Android device, please click on year to change it
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

If you use Android device, please click on year to change it
(if registered at another practice)
If you use Android device, please click on year to change it

Proxy access will be given to:

  • Book/cancel appointments
  • Request repeat medication
  • View the core medical record (medication & allergies)
  • View immunisations information

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

Privacy Consent

This form collects personal and medical information about you. We use this information to allow the practice team to contact you. Please read our Privacy Policy to discover how we protect and manage your submitted data.


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