Request Online Services

NHS Number*

To register you will need your NHS number. If you do not know your NHS number there is an online service which will help you find it. Click Here.

Your Name*

Title First Middle Last

Your Address*

Street Address Address Line 2 Town Post Code

Date of Birth*

Mobile Number*

Email*

Please confirm the following security questions:*

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

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 incorrect, I will contact the practice as soon as possible

Which Services do you wish to use?

Booking appointments Optional

Requesting repeat prescriptions Optional

View summary information in GP record (medications, allergies, bad reactions) Optional

Would you like someone else to have online access (Proxy Access) to your records?You can allow others to access your records on your behalf. This is known as ‘Proxy’ access. This provides the same information and services as individual access.

No Optional

Yes Optional

Please confirm your request

I give permission to my GP practice to give the person named below proxy access to the online services as indicated below Optional

I reserve the right to reverse any decision I make in granting proxy access at any time Optional

I understand the risks of allowing someone else to have access to my health records Optional

I have read and understand the information leaflet provided by the organisation Optional

Person to whom Proxy Access is Granted

First Optional Last Optional

Their relationship to you Optional

Their Contact Number Optional

Do you wish to use enhanced Services

No Optional

Yes Optional

Enhanced services provides you with a detailed view of your medical record

Which services do you wish to use?

Tests Optional

Documents Optional

Consultations Optional

Register or Update your Online Services

Online Services Request