Register for Online Services and/or Opt-in for prospective access to Online Records

DISCLAIMER, we are supportive of providing you with access to your record, but we wish to do this safely. You may wish to speak with us first to understand what it is that you will see, and the risks which may be involved in having such confidential data either on your smartphone with the NHS app installed or online if other people might have access to that information through your devices. We reserve the right to review your request and deny full access, if we believe this will pose a serious risk to our patient’s safety and/or to protect vulnerable patients.

For Online registration Only: To register for our online services you will need to complete this form and then visit the practice, bringing with you one form of identification, which should include your photograph. We will then issue you a username and password.

Last Updated: 23/11/2023

Register for Online Services and/or opt in for prospective access to Online Records

FULL NAME *

Title

Date of Birth *

YOUR NHS NUMBER *

Email Address *

Address AND POSTCODE *

CURRENT PHONE NUMBER *

WHICH ONLINE SERVICES WOULD YOU LIKE ACCESS TO? (tick all that apply) *

Allow Appointment booking (Currently unavailable)

Allow Medication Requesting

Allow Detailed coded full records

I WOULD LIKE TO HAVE PROSPECTIVE ACCESS TO MY FULL ONLINE RECORDS AND WISH TO OPT IN *

Yes No

DATE

Please note you must provide us with a proof of ID to process this request and create your online account. This could be a passport , Full British driving licence ,Travel document or a birth certificate. Once you completed this online form, Please visit the surgery to provide us your original identification document. Only then we are able to process your request. *

In order to confirm my identity, I will bring an original copy of my ID to reception desk.

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.

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Register for Online Services and/or Opt-in for prospective access to Online Records

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