Register for online access – under 11’s

Child’s First Name:

Child’s Surname:

Child’s Date of Birth:

Please use this date format: DD/MM/YYYY.

Phone Number:

Email Address:

(Use email address of the account you wish the child to be added to i.e. parent’s email)

Address, including postcode:

I understand that I will have access to these online services.

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

I will ensure I understand the information provided by the practice when I supply my ID.
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

My Chosen Pharmacy Is:

Pharmacy Name:

Pharmacy Address:

Pharmacy Postcode:

Proxy Registration: I am the patient’s representative, and I am registering on behalf of:

Patient’s Name:

Relationship to Patient:

Representative’s name:

Date of Birth:

Patient NHS Number

Practice computer ID number

Identity verified by (initials)

Date

Method

Vouching

Vouching with information in record

Photo ID and proof of residence

Authorised by

Date

Date account created

Date passphrase sent

Notes / explanation

To complete your registration please upload proof of identity, this should include Photographic ID/Birth Certificate and proof of address.

Maximum upload size: 67.11MB

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