Proxy Access Application - 11 and over

 

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Prerequisite

Please complete your on Application for Online Access before proceeding with this form.

ONLINE ACCESS APPLICATION

Patient’s Details

To give consent for proxy access to their online services

Patient Identification

To submit this request we need Two forms of Acceptable ID (if not possible, please let us know).

We will not store these documents and we will securely delete / destroy them after our initial verification.

OPTIONAL: Photo of your face to add to your records to help us identify you (if you agree)

Acceptable Identification: Photo Driving License, Passport, Tenancy agreement, Mortgage statement, Bank statement, Utility bill (date within the past 3 months) etc.

Declarations (Patient)

I,  , give permission to Castlegate & Derwent Surgery to give   proxy access to the online services as indicated in the next section.

 
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Representative 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 registered at another practice)

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

Representative Identification

To submit this request we need Two forms of Acceptable ID (if not possible, please let us know).

We will not store these documents and we will securely delete / destroy them after our initial verification.

OPTIONAL: Photo of your face to add to your records to help us identify you (if you agree)

Acceptable Identification: Photo Driving License, Passport, Tenancy agreement, Mortgage statement, Bank statement, Utility bill (date within the past 3 months) etc.

Declarations (Representative)

I,   wish to have online access to the services selected in the next section for  

 
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Consent

To be completed by the person named above unless lacks capacity because of medical condition

I give consent for the person named below to have online services access to: 

Please provide copy of legal paperwork (Power of Attorney/Court Appointed Deputy). If paperwork cannot be supplied then GP will need to confirm incapacity before access is given. 

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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