Request Proxy Access

Please complete the form below if you wish to request proxy access for a patient that is registered with us. We will need to carry out checks to confirm you identity and that the patient understands and consents to you being given access. We will contact you within 5 working days.

Your Details

ForenamePlease provide your forename

SurnamePlease provide your surname (family name)

Date of BirthPlease provide your date of birth

Telephone NumberPlease provide a telephone number we can use to contact you

Patient Details

ForenamePlease provide the forename of the patient you want access for

SurnamePlease provide the surname of the patient you want access for

Date of BirthPlease provide the date of birth of the patient you want access for

AddressPlease provide the full address of the patient you want access for

Access Requested

Please tick the services you are requesting access to

Appointment management

Repeat prescription requesting

Medical record access

If you have requested medical record access then you must confirm your agreement to each of the following

I will be responsible for the security of the information that I see or download.

I must not share the information I view with anyone else unless the patient agrees.

I will contact the practice as soon as possible if I suspect that my account has been accessed by someone without my consent.

I will contact the practice as soon as possible if I see information that is not about the patient or that I believe is incorrect.

Privacy Protection

Information submitted through secure forms is used only for the purposes of processing your request. We may be in touch with you in relation to the information submitted.

All Information submitted through secure forms is secured with a private key and is accessed over a secure connection by nominated staff. We have a strict confidentiality policy.

This information is not shared with any third party organisations.

This information is retained for up to 28 days.

I consent to my information being used for the purposes described above and wish to submit this online form to Levenshulme Medical Practice • Dunstable Street, Levenshulme, Manchester, M19 3BX.

Learn more about our Privacy Policy and Terms of Use. Should you have any concerns about sending your personal details using the web, please use one of the alternative methods offered by our organisation.

Local Services

Day
Nursery

Key Information

Request Proxy Access

Privacy Protection