Further access to online services

Address:

NHS Number:

I wish to have online access to:

View & book appointments

View & request medication

Complete online questionnaires

Access my Summary Care Record

Access my coded medical record

Access my full medical record

Please tick all that apply. Please note – you cannot have both coded & full medical record access)

I wish to access my medical record & understand & agree with each statement: *

I have read and understood the ‘Important Information’ section

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 log out immediately and contact the practice as soon as possible

Please attach photographic proof of your identification with this form, in order for the sign up process to be completed (if you do not have photo ID, please provide two forms of ID which confirms your name and address details instead).

Signature: *

Name: *

Date:

Please attach your files here:

Maximum upload size: 67.11MB

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Further access to online services