Proxy Access - Witton Street Surgery

To set up proxy access please come into the surgery and speak to a member of the reception team, they will ask you, and the patient you wish to set up proxy access for, to complete and sign a form.

Alternatively you can fill out the online form below:

Patient Information

Patient Name

First Last

Patient Date of Birth

Patient Preferred Contact Number Optional

Patient Address

Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country

Proxy User Information

Proxy User Name

First Last

Proxy User Date of Birth

Proxy User Preferred Contact Number Optional

Proxy User Address

Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country

Patient Signature

Proxy User Signature

Once this form is submitted it will take roughly 48 hours for the proxy access to be activated.

For more information about setting up Proxy access, please come into the surgery or call us, on 01606 544850, and we will be happy to advise on how this is done.