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

I understand and agree with all the above statements:

Signature *

Date *

The information you provide on this form will be sent to our practice and used only to deal with your request. Depending on the form, this may include your contact details, personal information and health information. The practice may add it to your medical record and, where needed for your care, share it with other NHS and care services. To find out how we protect and use your information, please read our privacy policy on our website.

I confirm the information I’ve given is correct and I understand how it will be used

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Application for Online Access

Further Information