Proxy Access - Upton Surgery

Accessing someone else’s information

As a parent, family member or carer, you may be able to access services for someone else. We call this having proxy access. We can set this up for you if you are both registered with us.

To requests proxy access please complete the form below:

Proxy Access Form

Proxy Access Patient Consent Form

The Patient

(The person whose records another individual(s) is to be given access to)

Name

First Last

Date of Birth

Gender

Male

Female

Address

Street Address Address Line 2 City Postcode

Phone Number

Details of person to be given access to this patient’s information

Name

First Last

Address

Street Address Address Line 2 City Postcode

Relationship to Patient

Is this access going to be limited in anyway?

Yes

If 'Yes', please specify limitations Optional

Prof of ID and Address

Drop files here or

Max. file size: 50 MB.

Please upload prof of your ID and prof of address

I confirm that I give permission for the Practice to communicate with the person identified above in regards to my medical records.

Your Signature

Date

Linked profiles in your NHS account

Once proxy access is set up, you can access the other person’s profile in your NHS account, using the NHS App or website.

The NHS website has information about using linked profiles to access services for someone else.