Register for Online Services & Messaging Consent Form

First Name *

Last Name *

Email *

This cannot be a shared email address if you require access to online services.

Date of birth *

Please use format day/month/year e.g. 12/05/1979

Mobile Phone Number *

If this mobile number is shared a form must be completed for each user.

Address *

May we contact you by SMS Text Messaging and email? *

Yes

Consent for SMS Text Messaging Service

We need to have your consent to begin communicating with you by text or email. Please tick to confirm your consent.

I consent to the Practice contacting me by text message for the purpose of health information and text reminders *

Yes

I confirm the mobile number is *

My own number

A number shared with others

I acknowledge that appointment reminders by text are an additional service and that they may not be sent on all occasions but that the responsibility for attending appointments or cancelling them still rests with me. *

Yes

Text messages are generated using a secure facility but I understand that they are transmitted over a public network onto a personal telephone and as such may not be secure. *

Yes

I understand I can cancel the text message facility at any time. *

Yes

Request Online Services

I wish to have access to the following online services *

Booking appointments

Requesting repeat prescriptions

Accessing my medical record (when available)

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 *

I agree

If I choose to share my information with anyone else, that is at my own risk *

I agree

If I suspect that my account has been accessed by someone without my agreement, I will contact the practice as soon as possible *

I agree

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 agree

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 agree

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
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? *

Deliver to the practice

Upload on this form

File Upload *

Maximum file size: 10MB

Please upload your files to the practice here. We accept tiff, jpg, png, gif, txt, Word and pdf files, up to a total upload size of 10MB.

Signature

Patient’s Signature *

Please type your name to sign your acceptance.

Privacy Policy

This form collects your name, date of birth, email, other personal information and medical details. This is to confirm you are registered with the practice, to allow the practice team to contact you and also to update your medical records held by the practice and our partners in the NHS. Please read our Privacy Policy to discover how we protect and manage your submitted data.

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

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Register for Online Services & Messaging Consent Form

Consent for SMS Text Messaging Service

Request Online Services

I wish to access my medical record online and understand and agree with each statement below:

Evidence of Identity

Signature

Privacy Policy

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