Tell us whether you accept cookies

We've put some small files called cookies on your device to make our site work. We would also like to use analytical cookies to understand how our site is used and improve user experience. Analytical cookies send information to Google Analytics.

Let us know your preference. We will use a cookie to save your choice. Before you make your choice you can read more about our cookie policy.

Skip to main content

The Docs NHS GP Surgery in Manchester

Consent to proxy access to GP online services

Patient details

This is the person whose records are being accessed

Surname: *

First Name: *

Date of Birth: *

Please use date format DD/MM/YYYY

Telephone Number:

Email Address: *

Address:

Including postcode

Does the patient have capacity to consent to grant proxy access? *

Yes

No

Patient consent *

I give permission to my GP practice to give the following people proxy access to the online services as indicated below. I reserve the right to reverse any decision I make in granting proxy access at any time. I understand the risks of allowing someone else to have access to my health records. I have read and understand the information leaflet provided by the practice.

Signature of patient: *

Date:

Online services requested

Online services you are requesting access to: *

Online appointments booking

Online prescription management

Accessing their medical record

Select all that apply

Representative 1 details

The person seeking proxy access to the patient’s online records, appointments or repeat prescriptions

Surname: *

First Name: *

Date of birth: *

Address:

Including postcode

Telephone Number: *

Email Address: *

Any responses from the practice will go to this email address

Representative 2 details

The second person seeking proxy access to the patient’s online records, appointments or repeat prescriptions

Surname:

First Name:

Date of birth:

Address:

Including postcode

Telephone Number:

Email Address:

I/we wish to have online access to the services selected above for the patient. I/we understand my/our responsibility for safeguarding sensitive medical information and I/we understand and agree with each of the following statements: *

I/we have read and understood the information leaflet provided by the practice and agree that I will treat the patient information as confidential

I/we will be responsible for the security of the information that I/we see or download

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

If I/we see information in the record that is not about the patient, or is inaccurate, I/we will contact the practice as soon as possible. I will treat any information which is not about the patient as being strictly confidential

Signature of representative 1: *

Signature of representative 2:

Date:

Upload a copy of your photo ID (for example, passport, driving licence) to help complete the process

Maximum upload size: 8.39MB

If you are human, leave this field blank.

55-59 Bloom Street
Manchester
M1 3LY

Get directions

0161 237 9490

Register with the surgery