Repeat Prescription Request

Full Name: *

Date of Birth: *

DD/MM/YYYY

Phone Number:

Please let us know your preferred contact number in case we need to contact you.

Email Address: *

Address, including postcode: *

Part A - to be completed by ALL applicants

Please indicate which of the following online services you would like access to: *

Booking appointments

Requesting repeat prescriptions

Access to my Summary Care Record

Select all that apply

I confirm that I will bring in the following proof of identification to complete my application (you will not be registered without this information): *

Proof of my identity - photo ID (passport/driving license)

Proof of my address (utility bill - dated within 3 months)

Part B - to only be completed if you wish to apply for Detailed Coded Records Access

Please ensure you read our Information Leaflets before submitting your application- they contain important information about the risks and responsibilities of access to your medical records:

Please note that your GP will review your request for online access to your medical records and this process may take a couple of weeks.

I wish to access my medical record online and understand and agree with each of the following statements:

1. I have read and understood the information leaflet provided by the practice

2. I will be responsible for the security of the information that I see or download

3. If I choose to share my information with anyone else, this is at my own risk

4. I will contact the practice as soon as possible if I suspect that my account has been accessed by someone without my agreement

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

Register for Online Services

Part A - to be completed by ALL applicants

Part B - to only be completed if you wish to apply for Detailed Coded Records Access

Terms and Conditions

Flu

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Repeat Prescription Request

Register for Online Services

Part A - to be completed by ALL applicants

Part B - to only be completed if you wish to apply for Detailed Coded Records Access

Terms and Conditions

Flu