Online Access Registration Form

Full name: *

PLEASE NOTE: Once you submitted this form you will have to present to the practice with Photo ID and proof of address. - WITHOUT THE ID VERIFICATION WE ARE UNBALE TO GIVE YOU ONLINE ACCESS. - If you do not present to the surgery with your ID documents within a week of submitting this form we will not proceed with the registration. The form and any data you submitted will be permanently deleted. I UNDERSTAND THAT I NEED TO PRESENT TO THE SURGERY WITH COPIES OF MY ID (PHOTO ID AND PROOF OF ADDRESS) WITHOUT ID VERIFICATION I WILL NOT BE GIVEN ACCESS. *

Date of Birth *

Home address: *

Home telephone : *

Mobile number: *

Can we send you text messages e.g. appointment confirmations, reminders etc? *

Consent for SMS / text messages

No consent for SMS / text messages

E-mail address *

Can we send you e-mails e.g. appointment confirmations, reminders etc ? *

Consent for e-mails

No consent for e-mails

I wish to have access to the following online services *

Booking appointments

Requesting repeat prescriptions

Summary Care Record

Detailed Coded Record

Please complete this section if you act on behalf of the patient requesting online access - Name of representative *

Relationship to patient *

Declaration: I have read and understood the information provided by the practice. I understand that I am responsible for the security of the information that I see or download. I understand that I am responsible for securing the username and password to prevent unauthorised persons from accessing the online records. If I choose to share my information with anyone else, this is at my own risk. If I see information in my/my child’s record that is not about me/my child or is inaccurate, I will contact the practice as soon as possible. In the event that mine or my child’s security details have been compromised, I will inform the practice immediately so that access can be blocked and new password issued. If at any time I wish to permanently cease internet access for me or my child, I will inform the practice in writing.

I confirm that I am *

the patient requesting access

the parent/guardian of the child mentioned above

a carer acting on behalf of the above mentioned patient and I have consent to do so

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