Register for online services

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Address, including postcode:

Please read the important information on our Registering for Online Services page before completing the form.

Before you apply for online access to your record there are some other things to consider. Please visit our Things to Consider When Applying for Online Access page.

I wish to have access to the following online services (tick all that apply):

Booking appointments

Requesting repeat prescriptions

I wish to have online access to my medical record

I have read an understood the information on this form
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 log out immediately and contact the practice as soon as possible

I understand and agree with the above statements

Signature:

Date

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