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.

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