Register for Online Services

To register for our online services you will need to complete this form. Once we have written to you, you will need to visit the practice with two forms of ID: one for a proof of name and another for proof of residence.

We will then issue you a username and password.

Once you are registered you will be able to use the service to:

• Order your repeat prescriptions
• Make an appointment
• Cancel an appointment
• Change your contact details
• Review your medications and known allergies

Register for Online Services

Register for Online Services

If you are human, leave this field blank.

Full Name: *

Date of Birth: *

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

Phone Number:

Email Address: *

Any responses we send will go to this email address.

Address, including postcode:

Access Required

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

Booking appointments

Requesting repeat prescriptions

Accessing my medical record

Terms and Conditions

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.

*

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

*

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

Signature: *

Date: