Register for Online Services Who are you completing this form for? Yourself Someone Else For example, on behalf of a child or dependentWhat is your name? First Last What is your date of birth? DD slash MM slash YYYY What is your sex? Female Male Other As recorded on your medical record What is your post code?The one used to register with your GP What is your phone number?What is your email address? Anyone else with access to your email account may see responses sent to you Address, including postcode OptionalI wish to have access to the following online services (please select all that apply): Booking Appointments Optional Requesting Repeat Prescriptions Optional Accessing my Medical Record Optional Terms and ConditionsI wish to access my medical record online and understand and agree with each statement: I have read and understood the Online Access for Patients – Important Information provided by the practice.Confirmation I will be responsible for the security of the information that I see or download.Confirmation If I choose to share my information with anyone else, this is at my own risk.Confirmation If I suspect that my account has been accessed by someone without my agreement, I will contact the practice as soon as possible.Confirmation If I see information in my record that is not about me or is inaccurate, I will contact the practice as soon as possible.Confirmation 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.Signature Optional