Register for online services proxy access (children under 12 or carers)

Details of Patient

Surname: *

First Name: *

Date of Birth: *

Please use this date format: DD/MM/YYYY

Address and Postcode: *

Is the patient under 12 years old? *

Yes

No

Details of Applicant

Surname: *

First Name: *

Date of Birth: *

Please use this date format: DD/MM/YYYY

Address and Postcode: *

Email Address: *

Any responses we send will go to this email address.

Relationship to patient: *

Preferred Contact Number: *

Additional Number:

I wish to have online access to book appointments and order repeat prescriptions for the patient named above and I understand and agree with each statement: *

I have responsibility for, and consent from the patient named above.

I will contact the practice as soon as possible if I suspect that the account has been accessed by someone without my agreement.

*

I enclose a letter of authorisation from the patient.

*

I understand that access to the patients electronic record will be closed during the month of their 12th birthday.

Signature: *

Date:

To complete your registration, please upload proof of identity, this should include photographic ID and proof of address.

Maximum upload size: 67.11MB

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Register for online services proxy access (children under 12 or carers)

Details of Patient

Details of Applicant