Proxy Access 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

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

Proof of ID and Address

Drop files here or

Max. file size: 1 GB.

Please upload proof of your ID and proof 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