Request to register for online services

To register for online services you will need to complete this form

Last Updated: 03/11/2023

  • My details

    Date of Birth
    For example, 15 3 1984

  • Online services request

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

  • Terms and conditions

    To access your medical records online, we ask that you read through, understand, and agree to each of the following statements.

    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
    If I suspect that my account has been accessed by someone without my agreement, I will contact the practice as soon as possible
    If I see information in my record that is not about me or is inaccurate, I will contact the practice as soon as possible
    If I think that I may come under pressure to give access to someone else unwillingly I will contact the practice as soon as possible
    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.

  • Identity verification

    In order to complete your online services registration, we need to verify your identity. There are a few ways that we can do this. Please provide an answer to TWO of the following questions.

    If you are unable to answer TWO of the above questions, please attend the surgery with some identification. (optional)
This form is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.