Register for online services

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 medications

Accessing my medical record

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 is not about me or is inaccurate, I will contact the

practice as soon as possible
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:

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