First Name *
Last Name *
Phone Number *
I wish to have access to the following online services
Please tick all that apply
I wish to access my medical record online and understand and agree with each statement below:
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, that 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
* Evidence of Identity
To register for Online Services we need to verify your identity. So, please provide the practice: One photo ID such as passport or drivers licence and one form of ID with your home address on such as a recent utility bill or bank statement. Copies can be uploaded on this form or delivered to the practice.
How would you like to provide evidence of your identity?
* File Upload *
Please upload your files to the practice here. We accept tiff, jpg, png, gif, txt, Word and pdf files.
If you are human, leave this field blank. Send