Online Access Form

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.

    Date of Birth
    For example, 15 3 1984
    I wish to have access to the following online services (please tick all that apply)
    I wish to access my medical record online and understand and agree with each statement (tick)
    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.
  • *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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