Register for Online Services

To register for our online services you will need to complete this form and then wait for a text from us asking you to take a photo of your photographic proof of ID e.g. passport or driving licence and text it to us.

We will then issue you a username and password.

Once you are registered you will be able to use the service to:

• Order your repeat prescriptions
• Make an appointment
• Cancel an appointment
• Change your contact details
• Review your medications and known allergies

Register for Online Services

Register for Online Services

If you are human, leave this field blank.

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):

*

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 compromised

*

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.

*

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.