To register for our online services you will need to complete this form and then please come into the surgery bringing with you 2 proofs of ID. One must be either a Driving Licence or passport with your photo on and the other a Proof of address, i.e utility bill or bank statement.

We will then provide you with your unique ACCESS ID number and PIN Registration Letter.

Once you are registered you will be able to use the service to:

• Order your repeat prescriptions
• Make an appointment
• Cancel an appointment
• Change your contact details
• Review your medications and known allergies

Full Name: *

Date of Birth: *

Please use this date format: DD/MM/YYYY.

Phone Number:

Email Address: *

Address, including postcode:

Terms and Conditions

I understand that It is my responsibility to keep my account secure by keeping my details confidential I understand that I can terminate my account at any time by contacting the surgery, or change my log in details by re-registering and that this form will be kept on my electronic records I understand that my registration will be revoked if I constantly miss or cancel appointments.

*

I accept the terms and conditions stated above

For Practice Use Only

Patient NHS Number

Practice computer ID number

Identity verified by (initials)

Date

Method

Vouching

Vouching with information in record

Photo ID and proof of residence

Authorised by

Date

Date account created

Date passphrase sent

Level of record access enabled

Prospective

Retrospective

All

Limited parts

Contractual minimum

Notes / explanation

Please note that the details you give will be used to update your medical records.