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 * 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
