Application for online access to my medical record (form)

(* = required field)

Patient Name *

Date of birth *

Address *

Email address *

I wish to have access to the following online services (please tick all that apply): *

Booking appointments

Requesting repeat prescriptions

Accessing my medical record

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

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

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

Signature *

First Name