Please let us know as soon as possible if you change your contact details or name. It is important that this is up to date in case we need to reach you.

Please note: If your name has changed due to Marriage or by Deed Poll, please provide a copy of the appropriate document (this is a requirement of the Department of Health).

Please complete this form in English.




If your name has changed due to Marriage or by Deed Poll, can you please provide us with a copy of the appropriate document (requirement of Department of Health).



Responses we send will go to this email address – no response will go to any email address unless we have seen ID and verified email address.

How do you wish to be known?
DrMrMrsMissMsOther

Would you have any objection to being reminded by text for appointments / health checks?
YesNo

We collect personal information when you enquire. We will use this information to provide the services requested and maintain records. We will not share your information for marketing purposes with any other companies. For more information explaining how we use your information please see our Privacy Policy

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

1. Booking appointments2. Requesting repeat prescriptions3. Accessing my medical record


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

1. I have read and understood the information leaflet provided by the practice2. I will be responsible for the security of the information that I see or download3. If I choose to share my information with anyone else, this is at my own risk4. I will contact the practice as soon as possible if I suspect that my account has been accessed by someone without my agreement5. If I see information in my record that is not about me or is inaccurate, I will contact the practice as soon as possible

Date (dd/mm/yyyy)

Please tick here to sign this form. This will be taken as your signature to proceed and that all details given are correct. The form cannot be submitted without this consent.

Thank you for completing the online services registration form.
We will send a verification email and contact you by phone within the next two working days to verify your ID.

*Required fields

 

Before you apply for online access to your record, there are some other things to consider.

Although the chances of any of these things happening are very small, you will be asked that you have read and understood the following before you are given login details.

Things to consider:

Forgotten history

There may be something you have forgotten about in your record that you might find upsetting.

Abnormal results or bad news

If your GP has given you access to test results or letters, you may see something that you find upsetting to you. This may occur before you have spoken to your doctor or while the surgery is closed and you cannot contact them.

Choosing to share your information with someone

It’s up to you whether or not you share your information with others – perhaps family members or carers. It’s your choice, but also your responsibility to keep the information safe and secure.

Coercion

If you think you may be pressured into revealing details from your patient record to someone else against your will, it is best that you do not register for access at this time.

Misunderstood information

Your medical record is designed to be used by clinical professionals to ensure that you receive the best possible care.  Some of the information within your medical record may be highly technical, written by specialists and not easily understood. If you require further clarification, please contact the surgery for a clearer explanation.

Information about someone else

If you spot something in the record that is not about you or notice any other errors, please log out of the system immediately and contact the practice as soon as possible.

More information

For more information about keeping your healthcare records safe and secure, you will find a helpful leaflet produced by the NHS in conjunction with the British Computer Society:

Keeping your online health and social care records safe and secure. Click here to see the leaflet.

 

Please Note

You will need to bring in two forms of ID to the surgery reception. One photo ID and one showing your address. Alternatively please make sure you enter your telephone so we can call you to verify details.

You will be sent an email from the practice which you will need to respond to. You will then receive an email with your user name and password. Please allow up to 7 working days.