Online Access Registration Form

If you wish to see your medical record from 2nd February 2023 onwards, book and manage your appointments, and request repeat prescriptions, all online, please complete this form to request access.

Please read the information leaflet before completing this form.

To protect the security, privacy and confidentiality of your medical record, we request two forms of VALID photo identification, for example:

Photograph UK driving licence
Passport
Student card
Disabled badge
NHS Card

If you only have 1 form of photo identification (listed above) then you will also need to provide:

Bank statement
Credit card statement
Building Society statement
Mortgage statement
P60
P45

If you have no form of photo identification then we will need to see 2 of the above.

Last Updated: 15/09/2023

Your details

First Name *

Surname *

Date of Birth *

Address *

Postcode *

Email address *

Contact number *

Online accesses

Which of the following services do you wish to have access to? *

Booking appointments

Requesting repeat prescriptions

Accessing my medical record

Confirmation statements

Please tick to confirm that you understand and agree with the following statements: *

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

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 it not about me, or is inaccurate I will log out immediately and contact the practice as soon as possible.

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Online Access Registration Form

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