Register for online services

What is your name?

First name

Last name

What is your date of birth?

For example, 31 3 1980

Day

Month

Year

What is your sex?

As recorded on your medical record

Male

Female

Other

What is your postcode?

The one used to register with your GP

What is your phone number?

What is your email address?

Anyone else with access to your email account may see responses sent to you

Address, including postcode:

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

Booking appointments

Requesting repeat prescriptions

Accessing elements of my medical record with the agreement of my GP

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

I have read and understood the Online Access for Patients – Important Information. I accept that it is my responsibility to maintain the security of any information that I see, download or choose to share with others.

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 will contact the practice, as soon as possible, if I suspect that any of my accounts have been accessed by someone without my agreement or if I see information in my record that is not about me or is inaccurate.

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.

The practice may withdraw my access to any online services, if it considers that they are being used inappropriately.

Are you happy to receive text and email notifications/updates from the surgery? Required

Yes

No

I accept the terms and conditions stated above

Signature: Required

Date:

Tell us whether you accept cookies

Register for online services

Out of Hours