Online Access Form

Last Updated: 01/07/2020

Online Access Form

To register for our online services you will need to complete this form. We will contact you once your request has been complete and will require to see a form of photo identification such as driving license or passport at this time. We will then issue you a username and password.

Surname *

First Name *

Date of Birth *

Address *

Email Address *

Telephone Number *

Mobile Number

I wish to have access to the following online services (please tick all that apply) *

Booking Appointments

Requesting Repeat Prescriptions

Accessing my Medical Records

I wish to access my medical record online and understand and agree with each statement (tick) *

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

2. If I choose to share my information with anyone else, this is at my own risk

3. If I suspect that my account has been accessed by someone without my agreements, I will contact the practice as soon as possible

4. If I see information in my record that is not about me or is inaccurate, I will contact the practice as soon as possible

5. If I think that I may come under pressure to give my access to someone else unwillingly I will contact the practice as soon as possible

I understand that It is my responsibility to keep my account secure by keeping my details confidential I understand that I can terminate my account at any time by contacting the surgery, or change my log in details by re-registering and that this form will be kept on my electronic records I understand that my registration will be revoked if I constantly miss or cancel appointments. *

I consent to the practice collecting and storing my data from this form.

*Please note that once a patient reaches 13 years of age, they will need to re-apply independently for on-line access.

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Online Access Form

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