Register for Online Services Form

Please note: If you wish to register for online services to access your repeat prescriptions, appointments etc., you are required to provide evidence of identification. Once this has been verified, we will issue the necessary documentation. If you have any further questions please contact the Practice.

First Name *

Last Name *

Email *

Date of birth *

Please use format day/month/year e.g. 12/05/1979

Phone Number *

Address *

I wish to have access to the following online services *

Booking appointments

Requesting repeat prescriptions

Accessing my medical record (when available)

Please tick all that apply

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

I will be responsible for the security of the information that I see or download *

I agree

If I choose to share my information with anyone else, that is at my own risk *

I agree

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

I agree

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 agree

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 *

I agree

Verify Your Identity

For your security, we are unable to create your Online Services account until you have provided 2 forms of ID to verify your identity. One form should be photographic ID (passport, driving license), and one should provide proof of your address dated within the last 3 months (utility bill, bank statement).

Once you have been contacted by the practice to confirm receipt of your application, you can bring your ID to the surgery for verification between 4pm-6pm Monday-Friday.

Privacy Policy

This form collects your name, date of birth, email, other personal information and medical details. This is to confirm you are registered with the practice, to allow the practice team to contact you and also to update your medical records held by the practice and our partners in the NHS. Please read our Privacy Policy to discover how we protect and manage your submitted data.

I consent to the practice collecting and storing my data from this form.

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Register for Online Services Form

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

Verify Your Identity

Privacy Policy

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Medicines Guide

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