Application for Online Access to GP Services Application for Online Access to GP Services (2) Full Name First Last Date of Birth Day Month Year Mobile NumberTelephone Number OptionalEmail Enter Email Confirm Email Address Street Address Address Line 2 City Post Code If you consent to be contacted by either of the following please tick: Email Mobile I do not consent I wish to have access to the following online services (please tick all that apply): Order Repeat Prescriptions Make an Appointment Cancel an Appointment Change personal details Review your medications and known allergies View Medical Records Select AllI 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.Confirmation I understand the above statement. confirmation 2 I consent to the practice collecting and storing my data from this form.
