Application for online access to my medical record (over 16 years only) Application for online access to my medical record Contact Details Full Name: * Date of Birth: * Please use date format DD/MM/YYYY Phone Number: Email Address: * Please note that by giving your email address you are consenting to receive confidential information (such as re-set passwords) to this address Home Address (include postcode): GP Name: I wish to have access to the following online services (please tick all that apply): * Booking appointments Requesting repeat prescriptions Viewing Test Results I wish to access my medical record online and understand and agree with each statement: * I have read and understood the information leaflet provided by the practice 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 contact the practice, in writing, as soon as possible PLEASE NOTE THAT ONLINE SERVICES CAN ONLY BE PROCESSED UPON RECEIPT OF TWO FORMS OF ID, ONE WITH PHOTOGRAPH i.e. PASSPORT OR DRIVING LICENCE AND ONE WITH PROOF OF ADDRESS. * I understand that it is my responsibility to provide the surgery with any change of contact details (address, telephone number, email address) Signature: * Date: Submit
