Register for Patient Access Online Services

Full Name: *

Date of Birth: *

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

Phone Number:

Email Address: *

Address, including postcode:

I wish to have access to the following online services:

Booking appointments

Requesting repeat prescriptions

Accessing my medical record

Please tick all that apply.

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 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

Signature: *

Date:

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

Register for Online Services