To register for our online services you will need to complete this form. To verify your identity we will call you and ask some security questions.

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
• View Medical Record

This service is only available to patients aged over 16.

Leaflet: Things to Consider about Online Services Records Access

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.

I wish to have access to the following online services (please click on all that apply)

Booking appointments

Requesting repeat medications

Accessing my medical record

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 and I have read and accepted the points listed in the 'Things to Consider' leaflet.