Register for online services

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Ethnicity:

White British

White Irish

Black Caribbean

Black African

Black Caribbean and White

Black African and White

Indian

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Bangladeshi

I do not wish to state

Other ethnic group

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Religion:

I wish to have access to the following online services (please select 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: *

I have read and understood the Online Access for Patients – Important Information 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.

I accept the terms and conditions stated above

Signature: *

Date:

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