Register for Online Services.

To register for our online services you will need to complete this form. and then visit the practice, bringing with you two forms of identification. One of these items should include your photograph. We will then issue you a username and password. If you require access to another patients records please fill out the proxy section.

Patient Details

Please fill out your details here or the patient that you are requesting access to.

Patient Name *

Date of Birth *

Phone Number *

Email Address *

Address *

Postcode *

Which online services would you like access to? (tick all that apply) *

Order Repeat Prescriptions

Make an Appointment

Cancel an Appointment

Change personal details

Review your medications and known allergies

View Medical Records

Proxy Access Request

Only fill in this section if you need to view another patient's notes, order their medication, or book their appointments. You will be required to attend the practice with the patient and bring both of your IDs to complete a separate form.

Name of person requesting proxy access

Date of Birth of person requesting proxy access

Relationship to patient

User Responsibilities and Data Security

I understand that it is my responsibility to keep my account secure by keeping my details confidential. I understand that I can terminate my account at any time by contacting the surgery, or change my login details by re-registering, and that this form will be kept on my electronic records. I understand that my registration will be revoked if I repeatedly miss or cancel appointments. If I am requesting proxy access, I accept responsibility for managing the patient's information securely and using it appropriately.

I consent to the practice collecting and storing my data from this form *

I consent to the practice collecting and storing my data from this form

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Page last reviewed: 26 February 2026
Page created: 15 February 2021

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Register for Online Services.

Register for Online Services.

Further Information