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Patient On-Line Access

Patient Access means that you can choose to:

  • Book and cancel appointments with your GP online
  • Order Repeat prescriptions
  • Look at the information in your medical record

You will be able to do this on a website or an app using a computer, a tablet or a smartphone.

Online services are free to use and are just another way of contacting your surgery.

How to apply

 

You can print off the application form and bring to the reception desk any time during opening hours with your ID. We will then generate your log on details within 48 hours.

Please note that two forms of ID are required to register for full access to Patient Access.  If you only want access to Booking Appointments and Requesting Repeat prescriptions you do not need to produce ID.

Photo ID (Passport or Driving License)

Proof of Address (Utility bill, Bank statement or letter from benefit agency)

PLEASE NOTE - Mobile phone bills and Store reward card letters are not acceptable

 

 

Churchtown Medical Centre - Access to GP online services

 

 

Surname

 

First Name

 

Date of Birth

 

Address

 

 

 

Postcode

 

Email address

 

Landline number

 

Mobile number

 

 

 

Preferred method on communication (PLEASE CIRCLE ONLY ONE)

Landline:    Mobile:     Email:     Text Message:      Letter:

 

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

 

Booking appointments

 

Requesting repeat prescriptions

 

Accessing my medical record

 

 

 

Application for online access to my medical record

 

I wish to access my medical record online and understand and agree with each statement (please tick all)

 

I have read & 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

 

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

 

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

 

 

 

Signature ………………………………………………………………………….                  

 

Date………………………………………………………………………………….

 

 

Please provide the following documents for proof of ID

 

Photo ID (Passport or Driving License)

Proof of Address (Utility bill, Bank statement or letter from benefit agency)

 

FOR ADMIN USE ONLY

 

Identity verified by staff member Signature………………………………………………..

 

Photo ID & proof of residence………………………………………………………..

Date……………………………………………………………….

 

 

 

 

 

 

 



 
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