Application for Online Services Application Form for Online Services Name Name First First Last Last Date Email Phone Phone I wish to have access to the following online services 1. Booking appointments 2. Requesting repeat prescriptions 3. Accessing my medical record (Please tick all that apply) I wish to access my medical record online and understand and agree with each statement 1. I have read and understood the information leaflet provided by the practice 2. I will be responsible for the security of the information that I see or download 3. If I choose to share my information with anyone else, this is at my own risk 4. If I suspect that my account has been accessed by someone without my agreement, I will contact the practice as soon as possible 5. If I see information in my record that is not about me or is inaccurate, I will contact the practice as soon as possible 6. 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. (Please tick all that apply) Signature Print full name Date If you are human, leave this field blank. Submit