Register for online services

Section

Address, including postcode:

Which surgery is normally attended?

East Harling Surgery

Kenninghall Surgery

Both

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

Booking appointments

Requesting repeat prescriptions

Accessing my medical record

The records we hold usually go back to your date of birth; from which year would you like access from? *

Terms and Conditions

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 constantly miss or cancel appointments.

I wish to have online access and understand and agree with each statement:

I will be completely 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 as soon as possible.
I confirm I will provide ID if asked.

*

I accept the terms and conditions stated above

Signature: *

Date:

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Section

Terms and Conditions