To register for our online services you will need to complete this form..

Please note we need to verify your identification and residency. You will need to come into the Surgery in person within 7 working days, with one Photo ID such as valid passport or drivers’ licence and with proof of residence, such as a utility bill addressed to yourself dated within the last 3 months.

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 summary record, medications and known allergies
• View your test results (subject to the GP’s discretion)

Your registration will not be processed until you have provided the required documents. If we have not received the requirements within 7 days your request will be deleted from the system.

Register for Online Services

If you are human, leave this field blank.

Full Name: *

Date of Birth: *

DD/MM/YYYY

Phone Number:

Please let us know your preferred contact number in case we need to contact you.

Email Address: *

Address, including postcode: *

Please state which surgery you are a patient at:

Part A - to be completed by ALL applicants

Please indicate which of the following online services you would like access to: *

Booking appointments

Requesting repeat prescriptions

Access to my Summary Care Record

Select all that apply

I confirm that I will bring in the following proof of identification to complete my application (you will not be registered without this information): *

Proof of my identity - photo ID (passport/driving license)

Proof of my address (utility bill - dated within 3 months)

Part B - to only be completed if you wish to apply for Detailed Coded Records Access

Please ensure you read our Information Leaflets before submitting your application- they contain important information about the risks and responsibilities of access to your medical records:

• Access to Medical Records
• Medical Records - Patient Information Leaflet
• Giving Another Person Access to your GP Online Services

Please note that your GP will review your request for online access to your medical records and this process may take a couple of weeks.

I wish to access my medical record online and understand and agree with each of the following statements:

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

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

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

4. I will contact the practice as soon as possible if I suspect that my account has been accessed by someone without my agreement

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