Over 16’s consent form for proxy access

Section

Details of person to be given proxy access

First name:

Last name:

Relationship to patient:

Address including postcode:

Phone number:

Email address:

Please tick the statement to confirm you consent.

I (the patient) hereby authorise my designated proxy to access my full medical records through the app services. This access includes viewing my medical records, test results, prescription history, and other relevant medical information.

Patient signature

Enter full name

Date

Termination of proxy access

If you would like to terminate proxy access, please email admin.woosehill@nhs.net and provide your name, date of birth, and the name of the person you would like to remove from your app. This can be done at any time by contacting the surgery.

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Over 16’s consent form for proxy access

Section

Details of person to be given proxy access

Termination of proxy access