Register for Online Services

Full Name *

Date of Birth *

Address *

Postcode *

Phone Number *

Email Address *

Which online services would you like access to? (tick all that apply) *

Change personal details

Make/amend an appointment

Order repeat prescriptions

Review medications and allergies

View a summary of your medical records (If selected please ensure you complete the below 'Online Access To Medical Records Questionnaire')

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 consent to the practice collecting and storing my data from this form.

Online Access To Medical Records Questionnaire

This questionnaire is about Online Medical Record Access and goes through the main issues you need to understand before you can access your records over the internet. This is NOT a test with a pass or fail – its purpose is to go through issues with you so that you feel happy to be able to decide whether you wish to access your records.

Further Information