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.

You will not be issued a username and password until you have come into the practice with your ID.

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

Register for Online Services

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: *

Address, including postcode:

I wish to have access to the following online services:

Booking Appointments

Requesting Repeat Prescriptions

Accessing My Medical Record

Please tick all that apply

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

For Practice Use Only

Patient NHS Number

Practice computer ID number

Identity verified by (initials)

Date

Method

Vouching

Vouching with information in record

Photo ID and proof of residence

Authorised by

Date

Date account created

Date passphrase sent

Level of record access enabled

Prospective

Retrospective

All

Limited parts

Contractual minimum

Notes / explanation