Access to GP online Services

Section

Address:

Doctor:

I wish to have access to the following services:

Booking Appointments

Requesting repeat prescriptions

Accessing my medical record

*Please allow two working days for your electronic access to be activated.

Please note you will need to verify your identity with two forms of identification, one must contain a photo and one must contain address details. Acceptable documents include passports, photo driving licenses and bank statements, utility bills (not mobile telephone bills).

If you need any further information or assistance with this matter please ask at reception.

Application for online access to my medical record

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

I agree to my GP Practice giving me access to my record online

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 will be at my own risk.

I will contact the practice as soon as possible if I suspect that someone without my agreement has accessed my account.

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.

I understand that I may see information on my record that I was unaware of/have forgotten about that could cause distress.

I understand that as before, I will be informed directly, by the practice, of any test results that require further action. However I understand that I may see these results online before the practice has been able to contact me. This could be while the surgery is closed and there is no one available to discuss them with me.

Signature: *

Date:

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Access to GP online Services