Register for online access

Please bring two forms of identification into Reception to register an account. If you are applying for proxy access on behalf of someone else, such as children aged 11 and over, or someone you care for, please complete the below form. This will then be reviewed by a manager to determine suitability.

First Name(s):

Surname:

Date of Birth:

dd/mm/yyyy

Telephone Number:

Email Address:

Address (including postcode):

First Name(s):

Surname:

Date of Birth:

dd/mm/yyyy

Telephone Number:

Email Address:

Address (including postcode):

I have read and understood the following conditions:

I give permission to my GP practice to give the following person proxy access to the online services as indicated in section 3.

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

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

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

Patient Signature:

Date:

dd/mm/yyyy