Register for Online Services

Full Name: *

Date of Birth: *

Please use this date format: DD/MM/YYYY.

Phone Number:

Email Address: *

Mobile Number:

Address, including postcode:

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

Booking appointments

Requesting repeat prescriptions

Accessing my medical record in summary

Access my medical record in detailed view (this will be subject to Practice Procedures)

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

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 my information with anyone else, this is at my own risk

I will contact the practice as soon as possible if I suspect that my 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

I (parent/s) of would like access to my child’s online medical notes. I understand my access will be revoked once my child turns 13 years

Terms and Conditions

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 accept the terms and conditions stated above

Signature:

Date:

For Practice Use Only

Patient NHS Number

Practice computer ID number

Identity verified by (initials)

Date

Method

Vouching

Vouching with information in record

Photo ID and proof of residence

Authorised by

Date

Date account created

Date passphrase sent

Notes / explanation

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