Register for online services

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:

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

Booking Appointments

Requesting Repeat Prescriptions

Access to my medical records

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 notify the practice in writing

For Practice Use Only

Identity verified by (initials):

Date:

Method:

Photo ID and proof of residence

Authorised by:

Date:

Date online account created:

Date of online account update:

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

Tell us whether you accept cookies

For Practice Use Only

Terms and Conditions