PLEASE COLLECT YOUR APPLICATION WITHIN TWO WEEKS OF YOUR REQUEST. IT WILL EXPIRE IF NOT REGISTERED WITHIN 28 DAYS Section A (to be completed by all) Full name of patient number Email Address (if applicable) Date of birth Address Section B (to be completed if you have ticked boxes 1 or 4) Full name of individual acting on Phone Number behalf of the patient (if different to above) Address (if different to above) Relationship to the patient Email Address I confirm that I have the authority to act on behalf of the above named patient and I understand that: If I am acting on behalf of a child under 12, once the child reaches 12 I will continue to have access however the practice will review this on an individual basis. If I am acting on behalf of a child who has reached the age of 16 my access will be removed and they will have to register on their own behalf. If I am acting on behalf of an individual who has impaired mental capacity my GP practice may require confirmation that I have relevant power of attorney. My access is at the discretion of the practice and can be removed at any time. Signature Date Section C (to be completed if you have ticked boxes 2 or 3) Full name of individual acting on Phone number behalf of the patient Email Address Address I confirm that I give authorisation on the above individual to act on my behalf. I understand that by allowing this individual to have access on my behalf they will see all appointments booked by myself including ones booked in person and over the phone. I also understand that if my practice offers repeat prescriptions online my nominated individual will see any repeat medication I am on. I understand that if I wish to remove access at any stage I can change my password online or contact the practice to do this for me.
PLEASE COLLECT YOUR APPLICATION WITHIN TWO WEEKS OF YOUR REQUEST. IT WILL EXPIRE IF NOT REGISTERED WITHIN 28 DAYS Section A (to be completed by all) Full name of patient number Email Address (if applicable) Date of birth Address Section B (to be completed if you have ticked boxes 1 or 4) Full name of individual acting on behalf of the patient Phone Number (if different to above) Address (if different to above) Relationship to the patient Email Address I confirm that I have the authority to act on behalf of the above named patient and I understand that: If I am acting on behalf of a child under 12, once the child reaches 12 I will continue to have access however the practice will review this on an individual basis. If I am acting on behalf of a child who has reached the age of 16 my access will be removed and they will have to register on their own behalf. If I am acting on behalf of an individual who has impaired mental capacity my GP practice may require confirmation that I have relevant power of attorney. My access is at the discretion of the practice and can be removed at any time. Signature Date Section C (to be completed if you have ticked boxes 2 or 3) Full name of individual acting on behalf of the patient Phone number Email Address Address I confirm that I give authorisation on the above individual to act on my behalf. I understand that by allowing this individual to have access on my behalf they will see all appointments booked by myself including ones booked in person and over the phone. I also understand that if my practice offers repeat prescriptions online my nominated individual will see any repeat medication I am on. I understand that if I wish to remove access at any stage I can change my password online or contact the practice to do this for me.