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.

Register for Online Services

Name *

Address *

Postcode *

Date of Birth *

Phone Number *

Email Address *

Which online services would you like access to? (tick all that apply) *

Order Repeat Prescriptions

Make an Appointment

Cancel an Appointment

Change personal details

Review your medications and known allergies

View Medical Records

I have read and understood the information leaflet *

Yes

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

Yes

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

Signature *

Date *

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Page last reviewed: 31 May 2022
Page created: 07 June 2022

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Register for Online Services

Register for Online Services

Further Information