Online Access Application

To register for our online services you will need to complete this form. One of the team will contact you to check your id. We will then provide you with the details you need to register for online services

Last Updated: 03/10/2022

Ethnicity

Ethnic Group

White British

White Irish

White Other

Black British

Black Caribbean

Black African

Black Other

Asian Indian

Asian Pakistani

Asian Chinese

Asian Other

White & Black British

White & Black Caribbean

White & Black African

White & Black Other

White & Asian

Other

I prefer not to say
Register for Online Services

Name

Date of Birth

Home Telephone Number (optional)

Mobile Telephone Number

Email address - THIS MUST NOT BE A SHARED EMAIL ADDRESS

Address

Postcode

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

Order Repeat Prescriptions

Make an Appointment

Cancel an Appointment

Change personal details

Review your medications and known allergies

View Medical Records

I confirm that if I spot something in the record that is not about me or notice any other errors, I will log out of the system immediately and contact the practice as soon as possible.

Yes

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

I consent to the Practice sending me text messages concerning my direct medical care

I consent to the Practice sending me emails concerning my direct medical care and Practice information

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Online Access Application

Ethnicity

Register for Online Services