Register for Online Services

To register for our online services you will need to complete this form and then visit the practice, bringing  with you two forms of identification. One of these items should include your photograph.

We will then issue you a username and password.

Once you are registered you will be able to use the service to:

• Order your repeat prescriptions
• Make an appointment
• Cancel an appointment
• Change your contact details
• Review your medications and known allergies

Register for Online Services

If you are human, leave this field blank.

Full Name: *

Date of Birth: *

Please use this date format: DD/MM/YYYY.

Phone Number:

Email Address: *

Any responses we send will go to this email address.

Address, including postcode:

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

Booking appointments

Requesting repeat prescriptions

Accessing my medical record

I wish to access my medical record online and understand and agree with each statement:

*

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

*

If I suspect that my account has been accessed by someone without my agreement, I will contact the practice as soon as possible

*

If I see information in my record that is not about me or is inaccurate, I will contact the practice as soon as possible

*

If I think that I may come under pressure to give access to someone else unwillingly I will contact the practice as soon as possible

Terms and Conditions

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 accept the terms and conditions stated above

Signature: *

Date

For Practice Use Only

Patient NHS Number

Practice computer ID number

Identity verified by (initials)

Date

Method

Vouching

Vouching with information in record

Photo ID and proof of residence

Authorised by

Date

Date account created

Date passphrase sent

Level of record access enabled

Prospective

Retrospective

All

Limited parts

Contractual minimum

Notes / explanation

Please note: all requests submitted through our website are triaged by our Receptionists who will pass your request onto the relevant medical professional.

If possible please upload your proof of identity, this should include Photographic ID and proof of address. If you are unable to upload your documents, please present them at the surgery.

Drop a file here or click to upload Choose File

Maximum upload size: 67.11MB