Register for online services

Address, including postcode:

I wish to have access to the following online services (please select 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 Online Access for Patients – Important Information 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.

Signature: *

Date:

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