Register for online services

Section

Address, including postcode:

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

Booking appointments

Requesting repeat prescriptions

Access to questionnaires

Access to my medical record (if you are newly registered, please allow time for the practice to receive and enter your previous notes on to your record)

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

I wish to receive text message confirmations and reminders for my appointments

I wish to receive letters from the practice via my email address

I wish to receive the Patient Newsletter via email (every 3 months)

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 wish to have online access and understand and agree with each statement:

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 contact the practice as soon as possible.

*

I accept the terms and conditions stated above

Signature: *

Date:

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Terms and Conditions