Register for online services

Address: *

I wish to have access to the following online services (please select all that apply):

Booking appointments

Requesting repeat prescriptions

Summary access to my medical record

If you require extended access to your medical record, covering current or past problems and test results, please ask the surgery for an additional form. This request will be passed to your GP to sign off.

Newly registered patients will need to wait until their medical records have been transferred for sign off.

I wish to access my medical record online and understand and agree with each statement: *

I have read and understood the Information Leaflet provided by the practice.

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

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

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

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

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

Patient Signature: *

Date:

To complete your registration, please upload proof of identity, this should include photographic ID and proof of address.

Maximum upload size: 8.39MB

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