Proxy Access Request Form Patient requesting permission to allow proxy accessPatient DetailsFull Name First Last Date of birth Day Month Year Address Street Address Address Line 2 City Postcode Contact NumberEmail Enter Email Confirm Email Named person receiving accessProxy DetailsFull Name First Last Address Street Address Address Line 2 City Postcode RelationshipAgreement as to what can be divulgedI give permission for the following to be permitted or discussed with the above-named person should they request: Appointments Medication Consultations Test Results Referrals (tick all that apply)