Proxy Access Application - Child under 11

 

BACK TO MAIN INDEX

 
Page {{ paginatorProps.current }} of {{ paginatorProps.total }} ({{ paginatorProps.percentage }}% completed)
Prerequisite

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

ONLINE ACCESS APPLICATION

Child’s Details

This section is for the child to give consent for proxy access to their online services to the proxy user

 
 
 

Child Identification

To submit this request we need the following identification, if this is not possible please let us know.

  • Birth Certificate
  • Passport

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

Only following file extensions are allowed: jpg, jpeg, png, webp, pdf, doc, docx, pptx
Only following file extensions are allowed: jpg, jpeg, png, webp, pdf, doc, docx, pptx
 
Previous Page  
Processing
Parent/Carer Details

This section should be completed by the Proxy user who is requesting access to the above name patient, we need this information to find your online access 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.

Parent/Carer Identification

Representative Identification

  • To submit this request we need two forms of identification one photographic and one proof of address, if not possible, please let us know. 
  • We also require a photograph of your face holding your photo ID

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

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

Only following file extensions are allowed: jpg, jpeg, png, webp, pdf, doc, docx, pptx
Only following file extensions are allowed: jpg, jpeg, png, webp, pdf, doc, docx, pptx
Only following file extensions are allowed: jpg, jpeg, png, webp, pdf, doc, docx, pptx
 
Previous Page  
Processing
Declarations (Parent/Carer)

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

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.

 
Previous Page  
Processing

There appears to be a problem loading the form, please refresh the page.
If the error persists please contact us.