To register for our online services you will need to complete this form, identification will then be verified over the phone.

We will issue you with a linkage key which will enable you to create a username and password.

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

• Order your repeat prescriptions
• Make an appointment
• Cancel an appointment
• Change your contact details
• Review your medications and known allergies

Please note we will take from 3-8 working days to process your application.

Register for Online Services

Register for Online Services

If you are human, leave this field blank.

Full Name: *

Date of Birth: *

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

Phone Number:

Email Address: *

Any responses we send will go to this email address.

Address, including postcode:

I wish to have access to the following services:

Book and cancel appointments

Requesting repeat prescriptions

Change personal details

Access to summary care records (medication record, adverse reactions/allergies etc)

Terms and Conditions

I understand that it is my responsibility to keep my account secure by keeping my details confidential I understand that I can terminate my account at any time by contacting the surgery, or change my log in details by re-registering and that this form will be kept on my electronic records I understand that my registration will be revoked if I constantly miss or cancel appointments.

*

I accept the terms and conditions stated above