Patient Online – Proxy Access | Oaks Place Surgery

Please use this form to request access to your child/another patient’s record. Access is granted at the discretion of the GP.

Access will not normally be granted if your child is aged over 10 years and 6 months. GP assessment of your child’s competency to consent may be required.

Information about Proof of identity documentation can be found here

Patient Online – Proxy Access

Parent/Carer Information

Name of Applicant

Applicant Date of Birth

Address (if different to patient)

Town

County

Postcode

Country

Mobile Phone Number

Consent

Consent to receive SMS messages from the practice

Patient Details

Please complete with details of the patient record you would like to access

Name of Patient

Patient’s Address

Patient's Address

Town

County

Postcode

Country

Patient’s Date of Birth

Relationship to Patient

Mother

Father

OtherOther

Identification

Please upload:
1 x Photo ID (Passport/Driving License)
1 x Address ID (bank statement, telephone bill, council tax statement)
1 x Child’s birth certificate

Photo ID

Maximum file size: 8.39MB

Address ID

Maximum file size: 8.39MB

Child’s Birth Certificate

Maximum file size: 8.39MB

I confirm that the information I have provided is accurate, please grant me proxy access to the above record. I understand that this is granted by the GP

reCAPTCHA