Online Access Application

Fill in the form below to apply for online services.

"*" indicates required fields

First name*

Surname*

Date of birth*

Address*

Postcode*

Email address*

Telephone number*

Mobile number

I wish to have access to the following online services (please tick all that apply):*

Booking appointments

Requesting repeat prescriptions

View Summary Information ( Medications, Allergies, Vaccinations)

View detailed information

Confirmation*

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. I understand I may read some information that could be unexpected or upsetting. 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 accessed by someone without my agreement. If I see information in my record that is not about me or is inaccurate, I will contact the practice as soon as possible.

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

Not for urgent medical help*

Yes, I understand this form is NOT for urgent medical help

Consent*

By submitting your details you are consenting to providing this information for improving our services to you. The data you supply on this form will be securely stored on our website, which is hosted by a third party. We will retain this information on the website for no longer than 7 calendar days. your contact details will not be sold or shared with a third party. I understand I can revoke this consent at anytime by contacting the practice. Our privacy policy can be viewed on this website.

I agree to the privacy policy.

Signature*

Type your name to sign the form. The practice may still need you to sign in person before they can provide you with login details.

Date*

Helpful links

Further Info