Online Services Form

Online Services Form

Online Services

Surname

First Name

Date of Birth
For example, 15 3 1984

Day

Month

Year

Address

Postcode

Email

Mobile Number

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

Requesting repeat prescriptions

Coded or summary access to parts of my medical record

Booking appointments

I wish to access my medical record online and understand and agree with each statement (tick)

I have read and understood the information leaflet 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

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Page last reviewed: 20 April 2026
Page created: 20 April 2026