Consent for medical care to be discussed with another person (proxy)

Patient Details

Patient’s First Name:

Patient’s Surname:

Date of Birth:

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

Email Address:

This is the email we can contact you with.

NHS Number (if known):

Representative’s Details

Full Name:

Date of Birth:

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

Telephone Number: *

NHS Number (if known):

Relationship to Patient:

Email Address: *

This email cannot match the same as the Patient Details

Telephone Consent

Consent

I am unable to ring the surgery for my appointments, medications and medical results and wish to designate a representative to do so on my behalf

Care to be Discussed:

Appointments

Repeat Medication

Investigations (Test Results)

Please select at least one

Duration:

Permanent

Until…

Until:

Please add duration ‘until’ date.

Online Access

Proxy access

I am happy for my representative (who is a patient at the practice) to have ‘proxy access’ to my medical information online.

Please note – If the representative does not have an online account with us, they must request this first; please ask at reception for more information.

I agree that my representative can access my medical record to:

Book Appointments

Order Repeat Prescriptions

See Investigations (Test Results)