Register for Online Services
Please use this date format: DD/MM/YYYY.
Any responses we send will go to this email address.
I wish to have access to the following online service (tick all that apply):
Which practice would you like to collect your username and password from?

Application for online access to my medical records

I wish to access my medical record online and understand and agree with each statement:

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.

For Practice Use Only

Method
Level of record access enabled