Online Application Form (Patient Facing Services)

Application for online access to Medical Records

Last Updated: 11/08/2021

Your Details

**If you are requesting access on behalf of a patient, this is known as PROXY access. We would require a signed letter of consent from the patient, ID from both parties and relationship to the patient.**





Level of Access Required

I wish to have access to the following online services (please tick all that apply):



Agreement for Online Access

I wish to access my medical record online and understand and agree with each statement (tick)





Additional Requirement

To grant you full access to Medical Records the practice will require that you attend in person with Photo ID (Driving License, or Passport etc). This ID will be copied and added to your Medical Records.

FOR PRACTICE USE ONLY