Application to view medical record online

Name *

Date of Birth *

Mobile Number *

Email Address *

I wish to have access to to the following online services *

Booking appointments

Requesting Repeat Prescriptions

Viewing my medical records

I wish to have access to my medical record online and understand and agree with the statements below *

I am over 13 years old

I will be responsible for the security of the information that I see or download

If I choose to share the information with anyone else, this will be at my own risk

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

If I see information in my record 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 my record to to someone else unwillingly I will contact the practice as soon as possible

THIS FORM COLLECTS YOUR NAME, DATE OF BIRTH, EMAIL, OTHER PERSONAL INFORMATION. THIS IS TO CONFIRM YOU ARE REGISTERED WITH THE PRACTICE, TO ALLOW THE PRACTICE TEAM TO CONTACT YOU. 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.

Application for online Access to medical record

Further Information

Cookies on the Park End Surgery website

Application for online Access to medical record

Further Information