Proxy Online Services Application

Proxy Online Services Registration

‘The Patient’s’ Details

Please complete text boxes as accurately as possible and select options where appropriate.
Include Flat, Room, Block Number and House Name
Enter Email
Confirm Email

‘The Patients’ ID

ID verification is required to ensure access is granted to correct patients and supports the Practice to adhere to information security guidelines. Please submit TWO forms of ID.
ID Form 1 – Proof of Photo Identification (passport, driving license or birth certificate) *
Maximum upload size: 5MB
We accept tiff, jpg, png, gif, txt, Word and pdf files, up to a total upload size of 5MB.
ID Form 2 – Proof of Address (bank statement or utility bill no more than 3 months old) *
Maximum upload size: 5MB
We accept tiff, jpg, png, gif, txt, Word and pdf files, up to a total upload size of 5MB.

‘The Representative’ Details

Please complete text boxes as accurately as possible and select options where appropriate.
Are you ‘The Representative’ a patient at Victoria Park Health Centre? *
Include Flat, Room, Block Number and House Name
Enter Email
Confirm Email

‘The Representative’ ID for Online Services

ID verification is required to ensure access is granted to correct patients and supports the Practice to adhere to information security guidelines. Please submit TWO forms of ID.
ID Form 1 – Proof of Photo Identification (passport, driving license or birth certificate) *
Maximum upload size: 5MB
We accept tiff, jpg, png, gif, txt, Word and pdf files, up to a total upload size of 5MB.
ID Form 2 – Proof of Address (bank statement or utility bill no more than 3 months old) *
Maximum upload size: 5MB
We accept tiff, jpg, png, gif, txt, Word and pdf files, up to a total upload size of 5MB.
I ‘the Representative’ understand my/our responsibility for safeguarding sensitive medical information about ‘the Patient’. I understand and agree to the following statements
I ‘The Representative’ will be responsible for the security of the information that I see or download. *
If I ‘The Representative’ choose to share this information with anyone else, this is at my risk. *
If I ‘The Representative’ suspect that the account has been accessed by someone without my agreement, I will contact the practice as soon as possible. *
If I ‘The Representative’ see information in ‘The Patients’ record that is not about them or is inaccurate, I will contact the practice as soon as possible. *
If I ‘The Representative’ think that I may come under pressure to give access to someone else unwillingly, I will contact the practice as soon as possible *

Signature

Please note: There is a slight delay after submitting this form while the information is processed. Please wait for the confirmation of successful submission message before closing this page or navigating away.