Application for Online Access

You will be required to email or attend the Practice with your identification.

Your Contact Details

Title *

Name *

Date of Birth *

Address *

Postcode *

Home Number

Mobile Number *

Email Address *

Online Access

I wish to have access to the following online service (Please choose all that apply) *

Cancelling/Viewing appointments (NOT YET AVAILABLE)

Requesting repeat prescriptions

Requesting acute prescriptions

I wish to use Online Services. Please read each statement carefully and tick ALL before signing *

I have understood the information provided by the practice

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

Children Aged 12-16

If you are aged 12-16 and you wish to continue using your parent’s mobile number/email, please tick this box and we will contact you again when you turn 16

Yes No

Proof of Identity and Address - You will need to either attend the Practice or email your documents as proof of your identity

Identity Document Type *

Birth Certificate

Driving Licence

Passport

Utility Bill

Allowance Book

Solicitors Letter

Offer of Tenancy

Other

I understand and agree with all the above statements:

Signature *

Date *

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Application for Online Access

Application for Online Access

Further Information