Proxy Access Patient Consent Form The Patient (The person whose records another individual(s) is to be given access to)Name First Last Date of Birth Day Month Year Gender Male Female Address of Patient Street Address Address Line 2 City Postcode Phone NumberPlease tick to confirm the areas of the online access you wish to allow someone else to access. Please select Make, Change to Cancel Appointments Review and Request Medication View Detailed Coded information from your Record View Full Clinical record information from no earlier than the date of this form Select AllDetails of person to be given access to this patient’s informationName First Last Address Street Address Address Line 2 City Postcode Relationship to PatientIs this access going to be limited in anyway? Yes No If 'Yes', please specify limitationsProof of ID and Address Drop files here or Select files 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. SignatureDate Day Month Year
