Proxy Access

Please complete this form is you are requesting proxy access, this will then be reviewed and you will be contacted if proxy access has been given. You will only be able to see appointments, medications, allergies and immunisations.

Proxy Access Request Form

Name of person requesting proxy access Required

First Last

Your date of birth Required

Your email address Required

Relationship to patient Required

If you have selected 'Other' please state relationship to patient Required

Name of patient you require proxy access for Required

First Last

Date of birth of patient Required

Additional Information

NHSE Patient Charter / You and your general practice

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Proxy Access

Proxy Access Request Form

Additional Information