Application for Online Access to my Medical Record

Application for Online Access to GP Services 

Before you apply for Online Access, it is important that you have read and understood the below information. 

1. It will be your responsibility to keep your login details and password safe and secure. If you know or suspect that your record has been accessed by someone that you have not agreed should see it, then you should change your password immediately. Access can also be gained on some phones using fingerprints or face ID – please consider this.

2. If you print out ANY information from your record, it is also your responsibility to keep this information secure. If you are worried about keeping printed copies safe, we recommend that you do not make copies at all.

3. The practice may not be able to offer online access due to several reasons such as concerns that it could cause harm to physical or mental health or where there is reference to third parties. The practice has the right to remove online access to services for anyone they feel it could harm or be put at risk

Things to consider

More information 

For more information about keeping your healthcare records safe and secure, we recommend that you read Protecting your GP Online Records

Application for Online Access to my Medical Records

Application for Online Access to GP Services

Name(Required)

First Middle Last

Date of Birth(Required)

DD slash MM slash YYYY

Address(Required)

Street Address Address Line 2 City County / State / Region Postcode AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country

Mobile Number(Required)

Email(Required)

Enter Email Confirm Email

Consent

I understand that my email address and/or mobile number may be used by the practice to contact me to provide health and care services. For example: appointment reminders, health campaign messages, messages relating to your own health and care e.g test results, surveys about our services.

If you consent to be contacted by either of the following please tick:(Required)

Email

Mobile

I do not consent

I wish to have access to the following Online Services (please tick all all that apply)(Required)

Access to FULL medical record

Requesting repeat prescriptions

Test Results

Documents

Immunisation History

Problems

I wish to access my online services and understand and agree with each statement (tick)(Required)

I have read and understood the information 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

If I see something in my records that I am unsure of and have not yet been contacted by the surgery, I will wait until usual opening times and not contact the out of ours or emergency services

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Upload your ID(Required)

Max. file size: 128 MB.

Print Name(Required)

First Last

Date(Required)

DD slash MM slash YYYY

Signature(Required)