To register for our online services you will need to complete this form and then visit the practice, bringing with you two forms of identification. One of these items should include your photograph and one needs to show recent proof of your address such as a utility bill or bank statement.

We will then pass your registration form to our patient services team for processing and will email you the information that you need in order to register your account.

Please ensure that when you fill in this form you supply us with your current email address – please note we need separate and unique email addresses for our patients due to the nature of our online services. Please be aware that we cannot use this form to register any patients under the age of 16 as we are in the process of adding new proxy access forms to the website. In the meantime please come down to the surgery as we have copies of the proxy access forms that can be used in the interim

Once you are registered you will be able to use the service to:

• Book appointments
• Request repeat prescriptions
• Access your medical records

Patient Information

• Patient Information Leaflet
• Comments Leaflet for Patients

Register for Online Services

If you are human, leave this field blank.

Surname: *

Firstname *

Date of Birth: *

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

Address, including postcode: *

Email Address: *

(NOTE: By supplying this email address you are giving authority for your online access sign up details to be emailed to this address - each patient MUST have their own email address)

Home Telephone Number:

Mobile Number:

Please specify which surgery you are a patient at: *

Marlow Surgery

Lane End Surgery

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

Booking appointments

Requesting repeat prescriptions

Accessing my medical record

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

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

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

If I see information in my record that is not about me or is inaccurate, I will contact the practice as soon as possible

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

Signature: *

Date:

Please tick if you are under 16 years as GP approval required

Signature of Parent Guardian

(If child under 16 years)

Date

For medico-legal reasons, before we are able to permit you access to your medical records summary, we require two separate forms of ID to verify both your identity and your address which you must present in person for verification by one of our reception staff.

Acceptable forms of photo ID are a passport or photo driving licence and proof of address can be in the form of a recent utility bill (not mobile phone), bank statement, tenancy agreement or council tax bill etc.

Your details will then be passed to our patient services team who will email you the information you need to register your account.

If you already have an online account which you use to book appointments and/or request repeat prescriptions, then you can use your existing user credentials and additionally have access to view your medical records summary once you have activated this facility.

For Practice Use Only

Patient NHS Number

Practice computer ID number

Identity verified by (initials)

Date

Method

Vouching with information in record

Photo ID and proof of residence

Verify using data held in the record (if no ID)

Authorising GP (adult Patient):

To confirm patient does not have any physical or mental illness, meaning that to view their medical notes will cause serious physical or mental harm to the patient or another person.

Date

Authorising GP (Child Patient

To confirm child under 16 years is Gillick Competent to have own access

Date account created

Date log in details sent