Register for online services

Section

Address:

Do you consent to being contacted by text and to receive appointment reminders?

Yes

No

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

Booking appointments

Requesting repeat prescriptions

Accessing my medical record

I wish to access my medical record online and understand and agree with each statement below (please tick):

Terms and conditions

I have read and understood the information leaflet provided by the practice

Terms and conditions

I will be responsible for the security of the information that I see or download

Terms and conditions

If I choose to share my information with anyone else, this is at my own risk

Terms and conditions

I will contact the practice as soon as possible if I suspect that my account has been compromised

Terms and conditions

If I see information not concerning me I shall log out and inform the practice

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.

Terms and conditions

I accept the terms and conditions stated above

Patient Signature:

Date:

Patient Parent/Guardian’s Signature:

(Under 16s)

Date:

Please give as much detail as possible to enable us to process your query effectively, and remember to check your spam folder for a response.

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Section

Terms and Conditions